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Based on observation, the facility failed to maintain the corridor doors. This was evidenced by doors that were obstructed from latching. This affected one of eight smoke compartments and could result in a delay in containing smoke or fire to a room.

NFPA 101 Life Safety Code, 2000 Edition
19.3.6.3 Corridor Doors.
19.3.6.3.2* Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

Findings:

During a tour of the facility with Plant Operations Staff on 9/11/13, the corridor doors were observed.

1. At 11:09 a.m., the Housekeeping Closet across from Operating Room (OR) 5 failed to latch. The door failed to latch due to duct tape that was placed over the striker plate.

2. At 11:23 a.m., the door to OR 1 failed to latch when tested. The striker in the door was hitting the latch plate in the door frame.

Based on observation, the facility failed to ensure that doors were held open by approved devices. This was evidenced by a door that was held open by carts. This affected one of eight smoke compartments and could result in the expedited spread of smoke or fire.

NFPA 101, Life Safety Code, 2000 Edition
7.2.1.8.1* A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.
7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code?.
(4) Upon loss of power to the hold-open device, the hold open mechanism is released and the door becomes self closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Findings:

During a tour of the facility with Plant Operations Staff on 9/11/13, the doors in exit passageways were observed.

1. At 10:17 a.m., in the PACU area, the self-closing door to the supply room was held open by two carts. The room contained combustible materials and staff mailboxes.

Based on observation, the facility failed to maintain an egress path free of obstructions. This was evidenced by the placement of a trash bin outside an exit door. This affected one of eight smoke compartments and could result in delayed evacuation in the event of a fire or other emergency.

NFPA 101, Life Safety Code, 2000 Edition
7.1.10 Means of Egress Reliability.
7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
SECTION 7.3 CAPACITY OF MEANS OF EGRESS
7.3.4 Minimum Width.
7.3.4.1 The width of any means of egress shall be not less than that required for a given egress component in Chapter 7 or Chapters 12 through 42, and shall be not less than 36 in. (91 cm).
Exception No. 3: In existing buildings, the width shall be permitted to be not less than 28 in. (71 cm).
SECTION 19.2 MEANS OF EGRESS REQUIREMENTS
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.

Findings:

During a tour of the facility on 9/11/13, the exits and egress paths were observed.

1. At 10:39 a.m., near the entrance to the Operating Rooms, the egress path leading to the public way was obstructed by a 67-inch by 30-inch by 61-inch trash bin. The trash bin reduced the clear width of the egress path to approximately 17 inches.

Based on observation, document review, and interview, the facility failed to maintain their emergency lighting. This was evidenced by battery-operated emergency lighting units that were not tested for one month and by one emergency lighting unit that failed to illuminate when tested. This affected two smoke compartments on the Old Side of the Hospital and the Second Floor of the Clinic at Coffee Road Surgery Center. This could result in limited visibility during a power failure due to a malfunctioning emergency lighting unit.

NFPA 101, Life Safety Code, 2000 Edition
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During document review with Plant Operations Staff on 9/10/13 and a tour of the facility on 9/11/13, the emergency lighting unit test records were requested and reviewed and the emergency lights were tested.

1. At 10:56 a.m., documents indicated that the emergency lighting units were not tested during the month of August 2013. When interviewed, Plant Operations Staff 1 said testing was not performed for that month.

2. On 9/11/13 at 11:14 a.m., the emergency lighting unit located in the storage hallway near the back side of OR 5 and OR 6 failed to illuminate when tested.

Based on document review and staff interview, the facility failed to prepare staff to respond to disaster emergencies. This was evidenced by the absence of documentation that indicated semi-annual disaster drills were conducted within the past 12 months. This affected eight of eight smoke compartments in the Surgical Hospital, the Clinic at Coffee Road Surgery Center, and the Clinic at Valley Hyperbaric Oxygen Center. The lack of emergency preparedness disaster drills could result in a delayed staff response to a disaster emergency.

NFPA 99, 1999 Edition
11-5.3.9 Drills. Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.

Findings:

During document review with Plant Operations Staff on 9/10/13, the disaster drill records were requested.

1. At 2:10 p.m., there were no documents to indicate that two semi-annual disaster drills were conducted for the Surgical Hospital, the Clinic at Coffee Road Surgery Center, and the Clinic at Valley Hyperbaric Oxygen Center. Plant Operations Staff 1 stated the drills were conducted but that the records could not be located.

Based on document review and staff interview, the facility failed to prepare staff to respond to fire emergencies. This was evidenced by the facility's failure to conduct one quarterly P.M. shift fire drill at the Surgical Hospital and the failure to conduct quarterly fire drills at the Clinic at Coffee Road Surgery Center. This affected eight of eight smoke compartments in the Surgical Hospital and the Second Floor of the Clinic at the Coffee Road Surgery Center. This could result in a delayed staff response to a fire emergency.

Findings:

During document review with Plant Operations Staff on 9/10/13, the fire drill records were requested and reviewed.

1. At 1:50 p.m., no fire drills were conducted in the third quarter 2012 for the P.M. shift at the Surgical Hospital.

2. At 1:50 p.m., fire drill records were not available for review for the Clinic at the Coffee Road Surgery Center. When interviewed, Plant Operations Staff 1 said the records are maintained by the building owner.

Based on document review and staff interview, the facility failed to maintain the fire alarm system. This was evidenced by the absence of a current inspection and certification report. This affected eight of eight smoke compartments in the Surgical Hospital and the Second Floor of the Clinic at Coffee Road Surgery Center. This could result in a malfunction or a delayed notification of a malfunctioning fire alarm system..

NFPA 101, Life Safety Code, 2000 Edition
SECTION 9.6 FIRE DETECTION, ALARM, AND COMMUNICATIONS SYSTEMS
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

Findings:

During document review with Plant Operations Staff on 9/10/13, the Fire Alarm System Inspection and Certification report was requested and reviewed.

1. At 10:43 a.m., a document titled, "Fire Alarm System Record of Completion" dated 6/18/12 confirmed that an annual inspection was done on that date. When interviewed, Plant Operations Staff 1 stated that no annual fire alarm system inspection and certification was conducted since 6/18/12.

2. Plant Operations Staff 1 further stated that fire alarm system records at the Clinic at Coffee Road Surgery Center are maintained by the building owner.

Based on document review and interview, the facility failed to maintain the automatic fire sprinkler system. This was evidenced by incomplete annual maintenance testing of sprinklers in the Surgical Hospital, by no documentation that indicated when quarterly, annual, or five-year maintenance testing was performed at the Clinic at Coffee Road Surgery Center, and by items stored less than 18 inches below a deflector. This affected 8 of 8 smoke compartments at the Surgical Hospital and the Second Floor of the Clinic at Coffee Road Surgery Center. This could result in a malfunction or a delayed notification of a malfunctioning automatic fire sprinkler system.

NFPA 101, Life Safety Code, 2000 Edition
4.6.12 Maintenance and Testing.
4.6.12.1 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 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
1-4 Responsibility of the Owner or Occupant.
1-4.2 The responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer's instructions. These tasks shall be performed by personnel who have developed competence through training and experience.
1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.
Chapter 2 Sprinkler Systems
Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance
Buildings - Inspection - Annually (prior to freezing weather)
Hanger/Seismic Bracing - Inspection - Annually
Pipe and Fittings - Inspection - Annually
Sprinklers - Inspection - Annually
Main Drain - Test - Annually

Findings:

During document review with Plant Operations Staff on 9/10/13, the automatic fire sprinkler system inspection, testing, and maintenance documents were requested and reviewed. During a tour of the facility with Plant Operations Staff on 9/11/13, the automatic fire sprinkler system was observed.

1. At 11:54 a.m. on 9/10/13, a review of the sprinkler documents revealed that the annual inspection, testing, and maintenance of the automatic fire sprinkler system was conducted by facility staff. A document titled, "Fire Sprinkler Check Off Sheet" dated 7/29/13 indicated that staff "vacuumed dust off of sprinklers." When asked if the buildings, hangers, bracing, and other required annual inspections and tests were conducted, Plant Operations Staff 1 stated that they were not.

2. Quarterly, annual, and five-year inspection, testing, and maintenance documents for the automatic sprinkler system at the Clinic at Coffee Road Surgery Center were not available for review. Plant Operations Staff 1 said the documents were maintained by the building owner.

3. At 10:02 a.m. on 9/11/13, the Second Floor Pharmacy Medications Room on the "new side" of the Surgical Hospital was observed. Items were stored approximately 8 inches below a sprinkler deflector in that room.

Based on observation, the facility failed to maintain their portable fire extinguishers. This was evidenced by a portable fire extinguisher that was overcharged. This affected one of eight smoke compartments in the Surgical Hospital and could result in a malfunction with the portable fire extinguisher.

NFPA 101, Life Safety Code, 2000 Edition
9.7.4 Manual Extinguishing Equipment.
9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition
1-6 General Requirements.
1-6.2 Portable fire extinguishers shall be maintained in a fully charged and operable condition, and kept in their designated places at all times when they are not being used.
4-3 Inspection.
4-3.2 Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following:
(g) Pressure gauge reading or indicator in the operable range or position

Findings:

During a tour of the facility with Plant Operations Staff on 9/11/13, the portable fire extinguishers were observed.

1. At 9:51 a.m., the pressure gauge on the portable fire extinguisher in the Penthouse indicated that the portable fire extinguisher was overcharged.

Based on observation, the facility failed to maintain safe storage of their oxygen gas cylinders. This was evidenced by one oxygen E-cylinder that was free standing and unsecured. This affected one of eight smoke compartments in the Surgical Hospital and could result in damage to a compressed gas cylinder.

NFPA 99, Health Care Facilities, 1999 Edition
4-3.1.1.1 Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Findings:

During a tour of the facility with Plant Operations Staff on 9/11/13, the oxygen gas storage areas were observed.

1. At 10:35 a.m., in the Pre-Op area, one oxygen E-cylinder was free-standing on the floor and unsecured. A rack containing oxygen E-cylinders was located behind the unsecured tank.

3. At 11:23 a.m., in the Substerile Room designated for OR 3 and OR 4, a refrigerator blocked clear access to Electrical Panel CR 3. The panel door could not be opened.

4. At 11:52 a.m. in the "Old Side" Electrical Room, a floor scrubber blocked clear access to Electrical Panel EM. The panel was opened to a maximum distance of 7 inches.




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Based on observation, the facility failed to maintain their electrical wiring and equipment. This was evidenced by the use of extension cords as a substitute for fixed wiring and electrical panels that were obstructed. This affected two of eight smoke compartments in the Surgical Hospital and could result in an electrical fire or electrical shock.

NFPA 101, Life Safety Code, 2000 Edition
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70 National Electric Code, 1999 Edition
110-26. Spaces About Electrical Equipment.
Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by loc and key shall be considered accessible to qualified persons.
(b) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working
space, if in a passageway or general open space shall be suitably guarded.
400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permit in this Code

Findings:

During a tour of the facility with Plant Operations Staff on 9/11/13, the electrical wiring and equipment were observed.

1. At 10:10 a.m., an electrical panel labeled K1 in the Kitchen was obstructed by a black cart.

2. At 10:28 a.m., in the Business Office area, a surge protected multi-outlet extension cord had a small refrigerator, coffee machine, water cooler, lamination machine, stapler, and hole punch plugged into it.

Based on document review and interview, the facility failed to maintain a fire watch policy and procedure regarding the loss of automatic fire sprinkler system services. This affected eight of eight smoke compartments in the Surgical Hospital, the Second Floor of the Clinic at Coffee Road Surgery Center, and the Clinic at Valley Hyperbaric Oxygen Center. This could result in a delay in initiating and implementing interim life safety measures in the event the automatic fire sprinkler system went out of service.

Findings:

During document review with Plant Operations Staff on 9/10/13, the Policies and Procedures manuals were reviewed.

1. At 3:40 p.m., the document titled, "Failure of Fire Alarm System" in the Engineering Policies and Procedures manual dated June 2012, made reference to a Fire Watch Plan. There was no fire watch plan available for review. When interviewed, Plant Operations Staff 1 said the Fire Watch Plan would have to be located.

Based on document review and interview, the facility failed to maintain a fire watch policy and procedure regarding the loss of fire alarm system services. This affected eight of eight smoke compartments in the Surgical Hospital, the Second Floor of the Clinic at Coffee Road Surgery Center, and the Clinic at Valley Hyperbaric Oxygen Center. This could result in a delay in initiating and implementing interim life safety measures in the event the fire alarm system went out of service.

Findings:

During document review with Plant Operations Staff on 9/10/13, the Policies and Procedures manuals were reviewed.

1. At 3:40 p.m., a document titled, "Failure of Fire Alarm System" in the Engineering Policies and Procedures manual dated June 2012, made reference to a Fire Watch Plan. There was no fire watch plan available for review. When interviewed, Plant Operations Staff 1 said the Fire Watch Plan would have to be located.

Based on observation, the facility failed to maintain safe installation of their alcohol based hand rub (ABHR) dispensers. This was evidenced by ABHR dispensers that were mounted above ignition sources. This affected one of eight smoke compartments at the Surgical Hospital and could result in an ABHR ignited fire emergency.

Findings:

During a tour of the facility with Plant Operations Staff on 9/11/13, the ABHR dispensers were observed.

1. At 10:53 a.m., an ABHR dispenser in the Women's Locker Room, near the entrance to the suite of operating rooms, was mounted approximately six inches to the upper left of a light switch.

2. At 11:00 a.m., inside OR 8, an ABHR dispenser was mounted approximately six inches directly above two light switches.

Based on observation, the facility failed to maintain the corridor doors. This was evidenced by doors that were obstructed from latching. This affected one of eight smoke compartments and could result in a delay in containing smoke or fire to a room.

NFPA 101 Life Safety Code, 2000 Edition
19.3.6.3 Corridor Doors.
19.3.6.3.2* Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

Findings:

During a tour of the facility with Plant Operations Staff on 9/11/13, the corridor doors were observed.

1. At 11:09 a.m., the Housekeeping Closet across from Operating Room (OR) 5 failed to latch. The door failed to latch due to duct tape that was placed over the striker plate.

2. At 11:23 a.m., the door to OR 1 failed to latch when tested. The striker in the door was hitting the latch plate in the door frame.

Based on observation, the facility failed to ensure that doors were held open by approved devices. This was evidenced by a door that was held open by carts. This affected one of eight smoke compartments and could result in the expedited spread of smoke or fire.

NFPA 101, Life Safety Code, 2000 Edition
7.2.1.8.1* A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.
7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code?.
(4) Upon loss of power to the hold-open device, the hold open mechanism is released and the door becomes self closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Findings:

During a tour of the facility with Plant Operations Staff on 9/11/13, the doors in exit passageways were observed.

1. At 10:17 a.m., in the PACU area, the self-closing door to the supply room was held open by two carts. The room contained combustible materials and staff mailboxes.

Based on observation, the facility failed to maintain an egress path free of obstructions. This was evidenced by the placement of a trash bin outside an exit door. This affected one of eight smoke compartments and could result in delayed evacuation in the event of a fire or other emergency.

NFPA 101, Life Safety Code, 2000 Edition
7.1.10 Means of Egress Reliability.
7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
SECTION 7.3 CAPACITY OF MEANS OF EGRESS
7.3.4 Minimum Width.
7.3.4.1 The width of any means of egress shall be not less than that required for a given egress component in Chapter 7 or Chapters 12 through 42, and shall be not less than 36 in. (91 cm).
Exception No. 3: In existing buildings, the width shall be permitted to be not less than 28 in. (71 cm).
SECTION 19.2 MEANS OF EGRESS REQUIREMENTS
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.

Findings:

During a tour of the facility on 9/11/13, the exits and egress paths were observed.

1. At 10:39 a.m., near the entrance to the Operating Rooms, the egress path leading to the public way was obstructed by a 67-inch by 30-inch by 61-inch trash bin. The trash bin reduced the clear width of the egress path to approximately 17 inches.

Based on observation, document review, and interview, the facility failed to maintain their emergency lighting. This was evidenced by battery-operated emergency lighting units that were not tested for one month and by one emergency lighting unit that failed to illuminate when tested. This affected two smoke compartments on the Old Side of the Hospital and the Second Floor of the Clinic at Coffee Road Surgery Center. This could result in limited visibility during a power failure due to a malfunctioning emergency lighting unit.

NFPA 101, Life Safety Code, 2000 Edition
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During document review with Plant Operations Staff on 9/10/13 and a tour of the facility on 9/11/13, the emergency lighting unit test records were requested and reviewed and the emergency lights were tested.

1. At 10:56 a.m., documents indicated that the emergency lighting units were not tested during the month of August 2013. When interviewed, Plant Operations Staff 1 said testing was not performed for that month.

2. On 9/11/13 at 11:14 a.m., the emergency lighting unit located in the storage hallway near the back side of OR 5 and OR 6 failed to illuminate when tested.

Based on document review and staff interview, the facility failed to prepare staff to respond to disaster emergencies. This was evidenced by the absence of documentation that indicated semi-annual disaster drills were conducted within the past 12 months. This affected eight of eight smoke compartments in the Surgical Hospital, the Clinic at Coffee Road Surgery Center, and the Clinic at Valley Hyperbaric Oxygen Center. The lack of emergency preparedness disaster drills could result in a delayed staff response to a disaster emergency.

NFPA 99, 1999 Edition
11-5.3.9 Drills. Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.

Findings:

During document review with Plant Operations Staff on 9/10/13, the disaster drill records were requested.

1. At 2:10 p.m., there were no documents to indicate that two semi-annual disaster drills were conducted for the Surgical Hospital, the Clinic at Coffee Road Surgery Center, and the Clinic at Valley Hyperbaric Oxygen Center. Plant Operations Staff 1 stated the drills were conducted but that the records could not be located.

Based on document review and staff interview, the facility failed to prepare staff to respond to fire emergencies. This was evidenced by the facility's failure to conduct one quarterly P.M. shift fire drill at the Surgical Hospital and the failure to conduct quarterly fire drills at the Clinic at Coffee Road Surgery Center. This affected eight of eight smoke compartments in the Surgical Hospital and the Second Floor of the Clinic at the Coffee Road Surgery Center. This could result in a delayed staff response to a fire emergency.

Findings:

During document review with Plant Operations Staff on 9/10/13, the fire drill records were requested and reviewed.

1. At 1:50 p.m., no fire drills were conducted in the third quarter 2012 for the P.M. shift at the Surgical Hospital.

2. At 1:50 p.m., fire drill records were not available for review for the Clinic at the Coffee Road Surgery Center. When interviewed, Plant Operations Staff 1 said the records are maintained by the building owner.

Based on document review and staff interview, the facility failed to maintain the fire alarm system. This was evidenced by the absence of a current inspection and certification report. This affected eight of eight smoke compartments in the Surgical Hospital and the Second Floor of the Clinic at Coffee Road Surgery Center. This could result in a malfunction or a delayed notification of a malfunctioning fire alarm system..

NFPA 101, Life Safety Code, 2000 Edition
SECTION 9.6 FIRE DETECTION, ALARM, AND COMMUNICATIONS SYSTEMS
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

Findings:

During document review with Plant Operations Staff on 9/10/13, the Fire Alarm System Inspection and Certification report was requested and reviewed.

1. At 10:43 a.m., a document titled, "Fire Alarm System Record of Completion" dated 6/18/12 confirmed that an annual inspection was done on that date. When interviewed, Plant Operations Staff 1 stated that no annual fire alarm system inspection and certification was conducted since 6/18/12.

2. Plant Operations Staff 1 further stated that fire alarm system records at the Clinic at Coffee Road Surgery Center are maintained by the building owner.

Based on document review and interview, the facility failed to maintain the automatic fire sprinkler system. This was evidenced by incomplete annual maintenance testing of sprinklers in the Surgical Hospital, by no documentation that indicated when quarterly, annual, or five-year maintenance testing was performed at the Clinic at Coffee Road Surgery Center, and by items stored less than 18 inches below a deflector. This affected 8 of 8 smoke compartments at the Surgical Hospital and the Second Floor of the Clinic at Coffee Road Surgery Center. This could result in a malfunction or a delayed notification of a malfunctioning automatic fire sprinkler system.

NFPA 101, Life Safety Code, 2000 Edition
4.6.12 Maintenance and Testing.
4.6.12.1 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 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
1-4 Responsibility of the Owner or Occupant.
1-4.2 The responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer's instructions. These tasks shall be performed by personnel who have developed competence through training and experience.
1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.
Chapter 2 Sprinkler Systems
Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance
Buildings - Inspection - Annually (prior to freezing weather)
Hanger/Seismic Bracing - Inspection - Annually
Pipe and Fittings - Inspection - Annually
Sprinklers - Inspection - Annually
Main Drain - Test - Annually

Findings:

During document review with Plant Operations Staff on 9/10/13, the automatic fire sprinkler system inspection, testing, and maintenance documents were requested and reviewed. During a tour of the facility with Plant Operations Staff on 9/11/13, the automatic fire sprinkler system was observed.

1. At 11:54 a.m. on 9/10/13, a review of the sprinkler documents revealed that the annual inspection, testing, and maintenance of the automatic fire sprinkler system was conducted by facility staff. A document titled, "Fire Sprinkler Check Off Sheet" dated 7/29/13 indicated that staff "vacuumed dust off of sprinklers." When asked if the buildings, hangers, bracing, and other required annual inspections and tests were conducted, Plant Operations Staff 1 stated that they were not.

2. Quarterly, annual, and five-year inspection, testing, and maintenance documents for the automatic sprinkler system at the Clinic at Coffee Road Surgery Center were not available for review. Plant Operations Staff 1 said the documents were maintained by the building owner.

3. At 10:02 a.m. on 9/11/13, the Second Floor Pharmacy Medications Room on the "new side" of the Surgical Hospital was observed. Items were stored approximately 8 inches below a sprinkler deflector in that room.

Based on observation, the facility failed to maintain their portable fire extinguishers. This was evidenced by a portable fire extinguisher that was overcharged. This affected one of eight smoke compartments in the Surgical Hospital and could result in a malfunction with the portable fire extinguisher.

NFPA 101, Life Safety Code, 2000 Edition
9.7.4 Manual Extinguishing Equipment.
9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition
1-6 General Requirements.
1-6.2 Portable fire extinguishers shall be maintained in a fully charged and operable condition, and kept in their designated places at all times when they are not being used.
4-3 Inspection.
4-3.2 Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following:
(g) Pressure gauge reading or indicator in the operable range or position

Findings:

During a tour of the facility with Plant Operations Staff on 9/11/13, the portable fire extinguishers were observed.

1. At 9:51 a.m., the pressure gauge on the portable fire extinguisher in the Penthouse indicated that the portable fire extinguisher was overcharged.

Based on observation, the facility failed to maintain safe storage of their oxygen gas cylinders. This was evidenced by one oxygen E-cylinder that was free standing and unsecured. This affected one of eight smoke compartments in the Surgical Hospital and could result in damage to a compressed gas cylinder.

NFPA 99, Health Care Facilities, 1999 Edition
4-3.1.1.1 Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Findings:

During a tour of the facility with Plant Operations Staff on 9/11/13, the oxygen gas storage areas were observed.

1. At 10:35 a.m., in the Pre-Op area, one oxygen E-cylinder was free-standing on the floor and unsecured. A rack containing oxygen E-cylinders was located behind the unsecured tank.

3. At 11:23 a.m., in the Substerile Room designated for OR 3 and OR 4, a refrigerator blocked clear access to Electrical Panel CR 3. The panel door could not be opened.

4. At 11:52 a.m. in the "Old Side" Electrical Room, a floor scrubber blocked clear access to Electrical Panel EM. The panel was opened to a maximum distance of 7 inches.




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Based on observation, the facility failed to maintain their electrical wiring and equipment. This was evidenced by the use of extension cords as a substitute for fixed wiring and electrical panels that were obstructed. This affected two of eight smoke compartments in the Surgical Hospital and could result in an electrical fire or electrical shock.

NFPA 101, Life Safety Code, 2000 Edition
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70 National Electric Code, 1999 Edition
110-26. Spaces About Electrical Equipment.
Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by loc and key shall be considered accessible to qualified persons.
(b) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working
space, if in a passageway or general open space shall be suitably guarded.
400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permit in this Code

Findings:

During a tour of the facility with Plant Operations Staff on 9/11/13, the electrical wiring and equipment were observed.

1. At 10:10 a.m., an electrical panel labeled K1 in the Kitchen was obstructed by a black cart.

2. At 10:28 a.m., in the Business Office area, a surge protected multi-outlet extension cord had a small refrigerator, coffee machine, water cooler, lamination machine, stapler, and hole punch plugged into it.

Based on document review and interview, the facility failed to maintain a fire watch policy and procedure regarding the loss of automatic fire sprinkler system services. This affected eight of eight smoke compartments in the Surgical Hospital, the Second Floor of the Clinic at Coffee Road Surgery Center, and the Clinic at Valley Hyperbaric Oxygen Center. This could result in a delay in initiating and implementing interim life safety measures in the event the automatic fire sprinkler system went out of service.

Findings:

During document review with Plant Operations Staff on 9/10/13, the Policies and Procedures manuals were reviewed.

1. At 3:40 p.m., the document titled, "Failure of Fire Alarm System" in the Engineering Policies and Procedures manual dated June 2012, made reference to a Fire Watch Plan. There was no fire watch plan available for review. When interviewed, Plant Operations Staff 1 said the Fire Watch Plan would have to be located.

Based on document review and interview, the facility failed to maintain a fire watch policy and procedure regarding the loss of fire alarm system services. This affected eight of eight smoke compartments in the Surgical Hospital, the Second Floor of the Clinic at Coffee Road Surgery Center, and the Clinic at Valley Hyperbaric Oxygen Center. This could result in a delay in initiating and implementing interim life safety measures in the event the fire alarm system went out of service.

Findings:

During document review with Plant Operations Staff on 9/10/13, the Policies and Procedures manuals were reviewed.

1. At 3:40 p.m., a document titled, "Failure of Fire Alarm System" in the Engineering Policies and Procedures manual dated June 2012, made reference to a Fire Watch Plan. There was no fire watch plan available for review. When interviewed, Plant Operations Staff 1 said the Fire Watch Plan would have to be located.