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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 failed to ensure that all automatic shutdown devices were tested annually. The facility used corridors as plenums.

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

Findings:

1. On 6/4/15 the evaluator conducted a follow up visit for a complaint validation survey dated 2/5/15, for a fire that occurred on the roof, and at air handler 2 of the pavilion building on 1/29/15. Relays at the air handler control panel were found to have been disconnected, permitting air handlers 1 and 2 to not shut down with the presence of smoke, dispersing smoke from the roof and air handler 2, to other areas and floors of the pavilion.

During the complaint validation survey dated 2/5/15, review of fire alarm system inspection and test reports dated 7/28/14, and 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. The last documented evidence of duct smoke detectors for air handler one and two being inspected was on 3/20/12.

On 6/4/15 at 1:25 p.m., during document review, there was no documented evidence that the duct detectors for air handlers at the 7th floor penthouse were inspected and tested. There was also no documented evidence of any inspection and testing of duct detectors for the new temporary air handler.

During an interview, at the same time as the document review the VP of Corporate Facilities Operations stated that the Fire Alarm System Vendor/Technician has been testing the automatic shutdown devices continuously during the installation of the new fire alarm control panel and new temporary air handler, and that Fire Alarm System Vendor/Technician will retest the automatic shutdown devices again at the end of the project, and provide a written report.

2. On 6/4/15 the evaluator conducted a follow up visit for a complaint validation survey dated 2/5/15. As a result of the complaint validation survey dated 2/5/15 it was revealed through interview of the Lead Man, and review of the tower building's supply and exhaust conveyance document, that Tower floors 4, 5, and 6 (T-4, T-5, and T-6) had plenums as part of the buildings air distribution system.

T-6, was a Med-Detox unit.

T-5 had been used as turn around space to house patients while the cleaning from the fire incident was done at the Pavilion.

T-4 was not on the facility's license and was not used for patients.

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.

On 6/4/15 at 1:25 p.m., during document review, OSHPD Verification Compliance Report dated 2/24/14 indicated that the Inspector of Record (IOR) inspected and tested the new fire alarm control panel and system in the "Tower Building" to be in full operation. That every device in the system had been tested and inspected for alarm, trouble, supervisory, ground fault, end of line voltage drop, air handler shut down, damper activation/operation, and dialer verification.

During an interview, the VP of Corporate Facilities Operations stated that nothing had changed in the Tower building since the complaint validation survey dated 2/5/15.

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.

The CMS S&C-06-18 letter dated 5/26/06, also indicated that in the cases where it is determined that the corridor is being used as a plenum and the deficiency is cited at tag K-067, a waiver may be granted. The letter further indicated that one of the criteria that should be used when considering the waiver request is that for partially sprinklered or unsprinklered buildings. if the zone with the corridor plenum is protected by a complete corridor smoke detection system, and there is provision for automatic fan shut down upon detection of smoke and activation of the building fire alarm system, a waiver may be recommended.