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Based on observation, record review, and interview, the facility failed to ensure that the 2 of 4 elevators Phase II firefighter operation were fully functional at all times.

Finding:

On February 3, 4, and 5, 2015, the evaluator conducted a complaint investigation into a fire / evacuation emergency.

On February 5, 2015, the elevator requested the Pavilion elevator test and service documentation for all four elevators. The Building Engineer provided the service test documents and he explained that the State of California were slow in sending the current annual certificates.

The evaluator reviewed the elevator documents and observed the following: North Elevator - the Phase II Operation failed from June 2014 through December 2014; the Staff Elevator - the Phase II Operation failed from August 2014 through December 2014; and the Service Elevator - the Phase II Operation failed from May 2, 2014 through July 16, 2014.

The evaluator conducted a record review of the elevator's certificates posted and 2 of 2 elevators certificates were expired. One of the certificates expired on October 18, 2014 and the other expired on September 30, 2014. On February 13, 2015, at 11:30 a.m., the evaluator contacted the State of California, Department of Industrial Relations, Div of Occupational Safety & Health, and staff verified that the two elevators failed the Phase II annual test. The staff also stated that the facility was fined because the two elevators' Phase II were not repaired within the time period initially allowed, 5-weeks.

The evaluator reviewed the fire incident report and it revealed that "Since the keys in the knox (security) box did not have the correct elevator recall key nor did security. Engineer T2 proceeded to recall elevators to the first floor and pull the "Emergency Stop" button in elevator panel."

Under Phase I operation, elevators that are 25 feet or more above the main floor return either to a designated landing area or an alternate area. Phase I operation is activated either manually by a special key, or automatically by a fire alarm initiating device.

The elevator Phase II operation is an override meant for firefighters after Phase I has been activated. Under the Phase II operation, firefighters can use a key-switch to operate the elevator, provided the hoistway is clear of smoke and the elevator has electricity.

NFPA 90A, Standard for the Installation of Air Conditioning and Ventilating Systems.

2-3.11.1 Egress Corridors in health care, detention and correctional and residential occupancies shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas. An air transfer opening(s) shall not be permitted in walls or in doors separating egress corridors from adjoining areas.

Exception No.1: Toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces opening directly onto the egress corridor.

Exception No.2: Where door clearances do not exceed those specified for fire doors in NFPA 80, Standard for Fire Doors and Fire Windows, air transfer caused by pressure differentials shall be permitted.

Exception No.3: Use of egress corridors as part of the engineered smoke control system.

Exception No.4: In detention and correctional occupancies with corridor separations of open construction (e.g. grating doors or grating partitions).

4-3.1 Smoke dampers shall be controlled by an automatic alarm initiating device. Smoke dampers shall be permitted to be positioned manually from a command station.

4-4.1 All automatic shutdown devices shall be tested annually.

4-4.3 Smoke detectors provided as required by 4-4.2 shall automatically stop their respective fan(s) on detecting the presence of smoke.

NFPA 101 Code for Safety to Life from Fire in Buildings and Structures 2000 Edition

9.2.1 Air Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

9.3.1* General. Smoke control systems, where required or permitted by Chapters 11 through 42, shall have an approved maintenance and testing program to ensure operational integrity. The purpose of such smoke control systems shall be to confine smoke to the general area of fire origin and maintain use of the means of egress system.

9.6.5.1 A fire alarm and control system, where required by another section of this Code, shall be arranged to actuate automatically the control functions necessary to make the protected premises safer for building occupants.

9.6.5.2 Where required by another section of this Code, the following functions shall be actuated by the complete fire alarm system:
(1) Release of hold-open devices for doors or other opening protectives
(2) Stairwell or elevator shaft pressurization
(3) Smoke management or smoke control systems
(4) Emergency lighting control
(5) Unlocking of doors

19.3.4.4 Emergency Control. Operation of any activating device in the required fire alarm system shall be arranged to accomplish automatically any control functions to be performed by that device. (See 9.6.5.)

19.5.2.1 Heating, ventilating, and air conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer's specifications.

These codes and standards were not met as evidenced by:

Based on observation, interview and document review, the facility failed to ensure an air handler automatically shut down with the presence of smoke. The facility failed to ensure that all automatic shutdown devices were tested annually. The facility used corridors as plenums.

The deficiencies permitted, and had the potential to permit accelerated spread of smoke and gases during a fire.

Findings:

1. On 2/3/15, a review of an OSHPD Fire and Life Safety Field Visit Report dated 2/2/15, indicated that on 1/29/15 a fire appeared to have damaged the HVAC supply air-intake filter banks that apparently supply air to the 2nd, 4th, 5th, and 6th floor patient rooms. That the HVAC system did not automatically shut-down during the fire on 1/29/15 and the smoke from the fire was dispersed from the roof supply intake to other areas and floors of the building.

On 2/3/15 at 12:05 p.m., during an interview, the Project Manager stated that one of two air handlers (air handler 2) in the penthouse was affected by the fire, and that air handler 2 affected the 2nd, front 3rd SDU, 4th, 5th, and 6th floors that it served.

At 2:10 p.m., Air handler 2 was observed to have fire, heat, and smoke damage. There was a duct detector located at the main supply duct coming form the air handler. The air handler was in the penthouse located at the 7th floor roof level.

During an interview at the same time as the observation, the Project Manager and the Lead Man stated that the smoke from the fire should have activated the duct detectors to shut down both air handler 1 and 2 .

On 2/4/15 at at 11:05 a.m., during an interview, the Lead Man stated that every floor in the Pavilion had smoke dampers, and that there were two duct detectors in the main supply ducts located at the penthouse. That the way the system was suppose to function was that the duct detectors send a signal to the fire alarm control panel that activates the alarm and the panel sends a signal to the fire alarm air handler controls that shuts down the air handler motor. That on the day of the fire both air handler 1 and 2 had to be shut down manually at the air handlers, and that he did not know what part of the HVAC shut down system did not work.

The Lead Man also stated that there were relays in the fire alarm air handlers control panel at the penthouse that could bi-pass the air handler shut down system so that the air handlers do not shut down when the fire alarm system was activated, and that only engineering knew about the relays.

Between 11:05 a.m., and 12:40 p.m., the Corporate Vice President of Facilities Operations stated that the hospital engineers had not been asked about the relays.

At 2:18 p.m., the Corporate Vice President of Facilities Operations stated that he had found out from the Engineer that the relays at the fire alarm air handlers control panel had been found pulled (unplugged).

On 2/5/15 at 8:52 a.m., during an interview the Corporate Vice President of Facilities Operations stated that the 2nd shift Stationary Engineer had found the relays pulled.

On 2/5/15 at 10:10 a.m., during an interview, the Lead Man stated that on the day of the fire (1/29/15) he heard a code red announced from the 3rd floor, that he went to the 3rd floor and saw smoke coming from vents at the 3rd floor, that he went up to the penthouse and saw smoke coming from air handler 2, saw fire at the door of the air handler, and saw the air handler was still on, so he (manually) shut off the air handler.

The Lead Man also stated that the engineers can pull the relays in the fire alarm air handlers control panel if a vendor is scheduled to conduct a fire alarm test and then reconnect them after the test, that its was the practice when he came to the hospital, and its what they (engineering) have continued to do, that the relays have to be pulled otherwise air conditioning and heating is lost for the whole building and that there was no other reason to pull the relays.

The Lead Man further stated that he asked the engineers to log whenever they pull and reconnect the relays, but did not know if the engineers log when they pull and reconnect the relays, that he did not know who the last person that pulled the relays was, that he asked the engineer who worked on the day of the fire, and the engineer told him he did not pull the relays.

At 2:40 p.m., during an interview, the Lead Man stated that engineering was not logging when the relays in the fire alarm air handlers control panel were being pulled and reconnected.

On 2/5/15, at 2:42 p.m., during an interview, the 2nd shift Stationary Engineer stated that on 1/29/15 he had arrived to the hospital at 1:30 p.m., after the fire, and discovered there had been a fire on the roof of the Pavilion. That around 5 p.m. the Lead Man asked him to go up to the penthouse to the fire alarm air handlers control panel to check if the relays for air handlers 1 and 2 were installed in place. That upon opening the relay box he found both relays unplugged and laying at the bottom of the panel at which time he installed them in there place.

The 2nd shift Stationary Engineer also stated he did not know who pulled the relays.

2. On 2/4/15 at 12:40 p.m., a review of fire alarm system inspection and test report dated 7/28/14, indicated there was no documented evidence that the duct detectors for air handlers 1 and 2 at the 7th floor penthouse were inspected and tested.

During an interview, after reviewing the fire alarm system inspection and test report dated 7/28/14, the Corporate Vice President of Facilities Operations stated that he didn't see any evidence in the report that air handler one and two at the 7th floor penthouse were inspected and tested.

During an interview, after reviewing the fire alarm system inspection and test reports dated 7/28/14, the Lead Man stated that the duct detectors on the air handlers were shut down devices that were tested annually, that per his review of the fire alarm inspection and test report dated 7/28/14, there was no evidence in the report that air handler 1 and 2 at the 7th floor penthouse were inspected and tested. The Lead Man also stated that when he received the fire alarm inspection and test report he reviewed the deficiency sheet at the end of the report, but did not review the rest of the report to check that all systems were tested, and that he should have reviewed the full report.

A review of the facility's Fire Alarm and Inspection schedule for 2014 indicated that the smoke detection shut down devices for the HVAC system had an annual testing frequency and were supposed to be tested in July of 2014.

On 2/5/15 at 1:15 p.m., review of the fire alarm system inspection and test report dated 4/24/13, indicated there was no documented evidence that the duct detectors for air handlers 1 and 2 at the 7th floor penthouse were inspected and tested.

During an interview, after reviewing the fire alarm system inspection and test report dated 4/24/13, the Lead Man stated that he he didn't see any evidence in the report that air handlers 1 and 2 at the 7th floor penthouse were inspected and tested.

The last documented evidence of duct smoke detectors for air handler one and two being inspected was on 3/20/12.

3. On 2/5/15 between 10 a.m. and 12 a.m., the Lead Man stated that the tower building had plenums as part of the buildings air distribution system on some of the tower building floors, but that he would have to investigate to determine which floors had plenums.

A review of the tower building's supply and exhaust conveyance document indicated that Tower floors 2, 4, 5, and 6 (T-2, T-4, T-5, and T-6) had plenums as part of the buildings air distribution system.

On 2/17/15, between 2 p.m. and 4 p.m., the following condition existed in the Tower.

At T-6, a Med-Detox unit, the air duct in the corridor was an open system with air blowing into the open egress corridor space above the drop down suspended ceiling. There were no ducts branching out from the corridor air duct, and there were transfer openings in the egress corridor walls that separated patient rooms from the corridor. There were no ducts from the corridor duct to the patient rooms, and the egress corridor above the ceiling space was used as a portion of the supply air system serving the patient rooms.

During an interview at the same time as the observation, the Lead Man stated that there were no ducts between the corridor duct and the rooms. That the air duct in the corridor was an open system with air blowing into the open corridor space above the suspended ceiling, with that open space used as a plenum. That the air movement went from the open corridor duct, to the open space plenum above the corridor ceiling, to the transfer openings in the egress corridor walls, pulled through the transfer openings into the rooms by the direction of air flow of the the exhaust vents in the rooms taking the air out of the rooms.

T-6 is a Med-Detox unit that had patients and staff at the time of the observation.

At T-5, the corridor had hard lid ceilings. During an interview at the same time as the observation, the Lead Man stated that the air supply at T-5 had the same type of plenum system as T-6.

During an interview at the same time as the observation, the Corporate Vice President of Facilities Operations stated that T-5 was used last week as turn around space to house patients while the cleaning was done at the Pavilion.

At T-4, the corridor had hard lid ceilings. During an interview at the same time as the observation, the Lead Man stated that the air supply at T-4 had the same type of plenum system as T-6.

At the same time as the observation, during an interview, the Risk Manager stated that T-4 is not on the facility's license and is not used for patients.

At T-2 the air duct in the corridor above the drop down suspended ceiling was a closed system with ducts branching from the corridor duct to the patient rooms.

During an interview at the same time as the observation, the Lead Man stated that T-2 was completely ducted and did not have a plenum as part of the floors air distribution system.

The egress (exit) corridors of T-4, T-5, and T-6 were the same corridors used as a portion of the air supply (plenums).

T-2, T-4, T-5, and T-6 were not sprinklered.

T-2, T-4, T-5, and T-6 had smoke detectors in the corridors including at the elevator lobby.

T-2, T-5, and T-6 had smoke detectors in the rooms. T-4 did not have smoke detectors in the rooms.

Per an e-mail dated 2/9/15, from the Corporate Vice President of Facilities Operations, there was an automatic fan shut down for T-2, T-4, T-5, and T-6 upon detection of smoke and activation of the building fire alarm system.

Per CMS S&C-06-18 letter dated 5/26/06, NFPA 90A, "Installation of Air Conditioning and Ventilating Systems" document, 1999 Edition prohibits egress (exit) corridors in health care occupancies from being used as a portion of the supply, return or exhaust air system serving adjoining areas (2-3.11.1, 1999 ed.). This prohibits the corridor from being used as a plenum.

NFPA 70 National Electrical Code 1999 edition

110-3. Examination, Identification, Installation, and Use of Equipment
(a) Examination. In judging equipment, considerations such as the following shall be evaluated:
(3) Wire-bending and connection space
(4) Electrical insulation
(8) Other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment

110-12.(c) Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

310-2.(a) Insulated. Conductors shall be insulated.

These codes were not met as evidenced by:

Based on observation and interview, the facility failed to ensure 2 electrical cords were not compromised.

The deficient practice bypassed the safe use and maintenance of electrical cords and their safeguards against fire and electric shock.

Findings:

On 2/3/15, between 4:20 p.m. and 4:55 p.m., there were two extension cords connected to air scrubbers on the 3rd and 5th floors of the pavilion. Closer observation revealed the extension cords had damaged that consisted of their electrical cord protective jacket being pulled away from the plug, thereby exposing the electrical wiring beneath.

During an interview at the same time as the observations, the Corporate Vice President of Facilities Operations stated damaged extension cords would be removed.

Based on observation, record review, and interview, the facility failed to ensure that the 2 of 4 elevators Phase II firefighter operation were fully functional at all times.

Finding:

On February 3, 4, and 5, 2015, the evaluator conducted a complaint investigation into a fire / evacuation emergency.

On February 5, 2015, the elevator requested the Pavilion elevator test and service documentation for all four elevators. The Building Engineer provided the service test documents and he explained that the State of California were slow in sending the current annual certificates.

The evaluator reviewed the elevator documents and observed the following: North Elevator - the Phase II Operation failed from June 2014 through December 2014; the Staff Elevator - the Phase II Operation failed from August 2014 through December 2014; and the Service Elevator - the Phase II Operation failed from May 2, 2014 through July 16, 2014.

The evaluator conducted a record review of the elevator's certificates posted and 2 of 2 elevators certificates were expired. One of the certificates expired on October 18, 2014 and the other expired on September 30, 2014. On February 13, 2015, at 11:30 a.m., the evaluator contacted the State of California, Department of Industrial Relations, Div of Occupational Safety & Health, and staff verified that the two elevators failed the Phase II annual test. The staff also stated that the facility was fined because the two elevators' Phase II were not repaired within the time period initially allowed, 5-weeks.

The evaluator reviewed the fire incident report and it revealed that "Since the keys in the knox (security) box did not have the correct elevator recall key nor did security. Engineer T2 proceeded to recall elevators to the first floor and pull the "Emergency Stop" button in elevator panel."

Under Phase I operation, elevators that are 25 feet or more above the main floor return either to a designated landing area or an alternate area. Phase I operation is activated either manually by a special key, or automatically by a fire alarm initiating device.

The elevator Phase II operation is an override meant for firefighters after Phase I has been activated. Under the Phase II operation, firefighters can use a key-switch to operate the elevator, provided the hoistway is clear of smoke and the elevator has electricity.

NFPA 90A, Standard for the Installation of Air Conditioning and Ventilating Systems.

2-3.11.1 Egress Corridors in health care, detention and correctional and residential occupancies shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas. An air transfer opening(s) shall not be permitted in walls or in doors separating egress corridors from adjoining areas.

Exception No.1: Toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces opening directly onto the egress corridor.

Exception No.2: Where door clearances do not exceed those specified for fire doors in NFPA 80, Standard for Fire Doors and Fire Windows, air transfer caused by pressure differentials shall be permitted.

Exception No.3: Use of egress corridors as part of the engineered smoke control system.

Exception No.4: In detention and correctional occupancies with corridor separations of open construction (e.g. grating doors or grating partitions).

4-3.1 Smoke dampers shall be controlled by an automatic alarm initiating device. Smoke dampers shall be permitted to be positioned manually from a command station.

4-4.1 All automatic shutdown devices shall be tested annually.

4-4.3 Smoke detectors provided as required by 4-4.2 shall automatically stop their respective fan(s) on detecting the presence of smoke.

NFPA 101 Code for Safety to Life from Fire in Buildings and Structures 2000 Edition

9.2.1 Air Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

9.3.1* General. Smoke control systems, where required or permitted by Chapters 11 through 42, shall have an approved maintenance and testing program to ensure operational integrity. The purpose of such smoke control systems shall be to confine smoke to the general area of fire origin and maintain use of the means of egress system.

9.6.5.1 A fire alarm and control system, where required by another section of this Code, shall be arranged to actuate automatically the control functions necessary to make the protected premises safer for building occupants.

9.6.5.2 Where required by another section of this Code, the following functions shall be actuated by the complete fire alarm system:
(1) Release of hold-open devices for doors or other opening protectives
(2) Stairwell or elevator shaft pressurization
(3) Smoke management or smoke control systems
(4) Emergency lighting control
(5) Unlocking of doors

19.3.4.4 Emergency Control. Operation of any activating device in the required fire alarm system shall be arranged to accomplish automatically any control functions to be performed by that device. (See 9.6.5.)

19.5.2.1 Heating, ventilating, and air conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer's specifications.

These codes and standards were not met as evidenced by:

Based on observation, interview and document review, the facility failed to ensure an air handler automatically shut down with the presence of smoke. The facility failed to ensure that all automatic shutdown devices were tested annually. The facility used corridors as plenums.

The deficiencies permitted, and had the potential to permit accelerated spread of smoke and gases during a fire.

Findings:

1. On 2/3/15, a review of an OSHPD Fire and Life Safety Field Visit Report dated 2/2/15, indicated that on 1/29/15 a fire appeared to have damaged the HVAC supply air-intake filter banks that apparently supply air to the 2nd, 4th, 5th, and 6th floor patient rooms. That the HVAC system did not automatically shut-down during the fire on 1/29/15 and the smoke from the fire was dispersed from the roof supply intake to other areas and floors of the building.

On 2/3/15 at 12:05 p.m., during an interview, the Project Manager stated that one of two air handlers (air handler 2) in the penthouse was affected by the fire, and that air handler 2 affected the 2nd, front 3rd SDU, 4th, 5th, and 6th floors that it served.

At 2:10 p.m., Air handler 2 was observed to have fire, heat, and smoke damage. There was a duct detector located at the main supply duct coming form the air handler. The air handler was in the penthouse located at the 7th floor roof level.

During an interview at the same time as the observation, the Project Manager and the Lead Man stated that the smoke from the fire should have activated the duct detectors to shut down both air handler 1 and 2 .

On 2/4/15 at at 11:05 a.m., during an interview, the Lead Man stated that every floor in the Pavilion had smoke dampers, and that there were two duct detectors in the main supply ducts located at the penthouse. That the way the system was suppose to function was that the duct detectors send a signal to the fire alarm control panel that activates the alarm and the panel sends a signal to the fire alarm air handler controls that shuts down the air handler motor. That on the day of the fire both air handler 1 and 2 had to be shut down manually at the air handlers, and that he did not know what part of the HVAC shut down system did not work.

The Lead Man also stated that there were relays in the fire alarm air handlers control panel at the penthouse that could bi-pass the air handler shut down system so that the air handlers do not shut down when the fire alarm system was activated, and that only engineering knew about the relays.

Between 11:05 a.m., and 12:40 p.m., the Corporate Vice President of Facilities Operations stated that the hospital engineers had not been asked about the relays.

At 2:18 p.m., the Corporate Vice President of Facilities Operations stated that he had found out from the Engineer that the relays at the fire alarm air handlers control panel had been found pulled (unplugged).

On 2/5/15 at 8:52 a.m., during an interview the Corporate Vice President of Facilities Operations stated that the 2nd shift Stationary Engineer had found the relays pulled.

On 2/5/15 at 10:10 a.m., during an interview, the Lead Man stated that on the day of the fire (1/29/15) he heard a code red announced from the 3rd floor, that he went to the 3rd floor and saw smoke coming from vents at the 3rd floor, that he went up to the penthouse and saw smoke coming from air handler 2, saw fire at the door of the air handler, and saw the air handler was still on, so he (manually) shut off the air handler.

The Lead Man also stated that the engineers can pull the relays in the fire alarm air handlers control panel if a vendor is scheduled to conduct a fire alarm test and then reconnect them after the test, that its was the practice when he came to the hospital, and its what they (engineering) have continued to do, that the relays have to be pulled otherwise air conditioning and heating is lost for the whole building and that there was no other reason to pull the relays.

The Lead Man further stated that he asked the engineers to log whenever they pull and reconnect the relays, but did not know if the engineers log when they pull and reconnect the relays, that he did not know who the last person that pulled the relays was, that he asked the engineer who worked on the day of the fire, and the engineer told him he did not pull the relays.

At 2:40 p.m., during an interview, the Lead Man stated that engineering was not logging when the relays in the fire alarm air handlers control panel were being pulled and reconnected.

On 2/5/15, at 2:42 p.m., during an interview, the 2nd shift Stationary Engineer stated that on 1/29/15 he had arrived to the hospital at 1:30 p.m., after the fire, and discovered there had been a fire on the roof of the Pavilion. That around 5 p.m. the Lead Man asked him to go up to the penthouse to the fire alarm air handlers control panel to check if the relays for air handlers 1 and 2 were installed in place. That upon opening the relay box he found both relays unplugged and laying at the bottom of the panel at which time he installed them in there place.

The 2nd shift Stationary Engineer also stated he did not know who pulled the relays.

2. On 2/4/15 at 12:40 p.m., a review of fire alarm system inspection and test report dated 7/28/14, indicated there was no documented evidence that the duct detectors for air handlers 1 and 2 at the 7th floor penthouse were inspected and tested.

During an interview, after reviewing the fire alarm system inspection and test report dated 7/28/14, the Corporate Vice President of Facilities Operations stated that he didn't see any evidence in the report that air handler one and two at the 7th floor penthouse were inspected and tested.

During an interview, after reviewing the fire alarm system inspection and test reports dated 7/28/14, the Lead Man stated that the duct detectors on the air handlers were shut down devices that were tested annually, that per his review of the fire alarm inspection and test report dated 7/28/14, there was no evidence in the report that air handler 1 and 2 at the 7th floor penthouse were inspected and tested. The Lead Man also stated that when he received the fire alarm inspection and test report he reviewed the deficiency sheet at the end of the report, but did not review the rest of the report to check that all systems were tested, and that he should have reviewed the full report.

A review of the facility's Fire Alarm and Inspection schedule for 2014 indicated that the smoke detection shut down devices for the HVAC system had an annual testing frequency and were supposed to be tested in July of 2014.

On 2/5/15 at 1:15 p.m., review of the fire alarm system inspection and test report dated 4/24/13, indicated there was no documented evidence that the duct detectors for air handlers 1 and 2 at the 7th floor penthouse were inspected and tested.

During an interview, after reviewing the fire alarm system inspection and test report dated 4/24/13, the Lead Man stated that he he didn't see any evidence in the report that air handlers 1 and 2 at the 7th floor penthouse were inspected and tested.

The last documented evidence of duct smoke detectors for air handler one and two being inspected was on 3/20/12.

3. On 2/5/15 between 10 a.m. and 12 a.m., the Lead Man stated that the tower building had plenums as part of the buildings air distribution system on some of the tower building floors, but that he would have to investigate to determine which floors had plenums.

A review of the tower building's supply and exhaust conveyance document indicated that Tower floors 2, 4, 5, and 6 (T-2, T-4, T-5, and T-6) had plenums as part of the buildings air distribution system.

On 2/17/15, between 2 p.m. and 4 p.m., the following condition existed in the Tower.

At T-6, a Med-Detox unit, the air duct in the corridor was an open system with air blowing into the open egress corridor space above the drop down suspended ceiling. There were no ducts branching out from the corridor air duct, and there were transfer openings in the egress corridor walls that separated patient rooms from the corridor. There were no ducts from the corridor duct to the patient rooms, and the egress corridor above the ceiling space was used as a portion of the supply air system serving the patient rooms.

During an interview at the same time as the observation, the Lead Man stated that there were no ducts between the corridor duct and the rooms. That the air duct in the corridor was an open system with air blowing into the open corridor space above the suspended ceiling, with that open space used as a plenum. That the air movement went from the open corridor duct, to the open space plenum above the corridor ceiling, to the transfer openings in the egress corridor walls, pulled through the transfer openings into the rooms by the direction of air flow of the the exhaust vents in the rooms taking the air out of the rooms.

T-6 is a Med-Detox unit that had patients and staff at the time of the observation.

At T-5, the corridor had hard lid ceilings. During an interview at the same time as the observation, the Lead Man stated that the air supply at T-5 had the same type of plenum system as T-6.

During an interview at the same time as the observation, the Corporate Vice President of Facilities Operations stated that T-5 was used last week as turn around space to house patients while the cleaning was done at the Pavilion.

At T-4, the corridor had hard lid ceilings. During an interview at the same time as the observation, the Lead Man stated that the air supply at T-4 had the same type of plenum system as T-6.

At the same time as the observation, during an interview, the Risk Manager stated that T-4 is not on the facility's license and is not used for patients.

At T-2 the air duct in the corridor above the drop down suspended ceiling was a closed system with ducts branching from the corridor duct to the patient rooms.

During an interview at the same time as the observation, the Lead Man stated that T-2 was completely ducted and did not have a plenum as part of the floors air distribution system.

The egress (exit) corridors of T-4, T-5, and T-6 were the same corridors used as a portion of the air supply (plenums).

T-2, T-4, T-5, and T-6 were not sprinklered.

T-2, T-4, T-5, and T-6 had smoke detectors in the corridors including at the elevator lobby.

T-2, T-5, and T-6 had smoke detectors in the rooms. T-4 did not have smoke detectors in the rooms.

Per an e-mail dated 2/9/15, from the Corporate Vice President of Facilities Operations, there was an automatic fan shut down for T-2, T-4, T-5, and T-6 upon detection of smoke and activation of the building fire alarm system.

Per CMS S&C-06-18 letter dated 5/26/06, NFPA 90A, "Installation of Air Conditioning and Ventilating Systems" document, 1999 Edition prohibits egress (exit) corridors in health care occupancies from being used as a portion of the supply, return or exhaust air system serving adjoining areas (2-3.11.1, 1999 ed.). This prohibits the corridor from being used as a plenum.

NFPA 70 National Electrical Code 1999 edition

110-3. Examination, Identification, Installation, and Use of Equipment
(a) Examination. In judging equipment, considerations such as the following shall be evaluated:
(3) Wire-bending and connection space
(4) Electrical insulation
(8) Other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment

110-12.(c) Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

310-2.(a) Insulated. Conductors shall be insulated.

These codes were not met as evidenced by:

Based on observation and interview, the facility failed to ensure 2 electrical cords were not compromised.

The deficient practice bypassed the safe use and maintenance of electrical cords and their safeguards against fire and electric shock.

Findings:

On 2/3/15, between 4:20 p.m. and 4:55 p.m., there were two extension cords connected to air scrubbers on the 3rd and 5th floors of the pavilion. Closer observation revealed the extension cords had damaged that consisted of their electrical cord protective jacket being pulled away from the plug, thereby exposing the electrical wiring beneath.

During an interview at the same time as the observations, the Corporate Vice President of Facilities Operations stated damaged extension cords would be removed.