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Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain the two-hour fire rated separation to the clinic occupancy in accordance with Life Safety Code Section 18.1.2.1. This deficient practice could affect all patients, staff and visitors within the health care building should heat and smoke spread from a fire condition in the adjacent building. This was evidenced by the following:

Wall penetrations were not sealed to maintain the two-hour fire rating of the wall assembly, as required. The two hour wall (above the double 90 minute doors to the main clinic corridor) was observed to have a 3" x 3" hole in both layers of the gypsum board. The unsealed opening had a 110 volt armored cable through the opening.

A facility Maintenance Staff member acknowledged the penetration during a tour of the facility.

Life Safety Code Section 18.1.2.1 requires, in part, that sections of health care facilities that are classified as other occupancies be separated by two hour rated construction. Section 8-2.3.2.4 requires, in part, that penetrations and miscellaneous openings in fire barrier walls be filled with a material capable of maintaining the fire resistance rating of the barrier.

Based on observation during the survey, it was determined that the facility failed to install corridor doors in accordance with Life Safety Code Section 18.3.6.3.2. This deficient practice could affect all patients, staff and visitors within the patient sleeping wing smoke compartment should the egress corridor become untenable, due to smoke and heat transfer, via the non-latching corridor doors separating rooms from the egress corridor. This was evidenced by the following:

Corridor doors were not equipped with positive latching hardware, as required. The sliding doors on Observation Rooms #1 and #2 were not equipped with positive latching hardware.
Life Safety Code Section 18.3.6.3.2 (Corridor Doors): Doors shall be provided with positive latching hardware. Roller latches shall be prohibited.

Based on observation and staff interview during the survey, it was determined that the facility failed to arrange horizontal exit door release in accordance with the Life Safety Code Section 18-2.2.2.6 and 7.2.1.8.2. This deficient practice could affect all patients, staff and visitors within the health care building should heat and smoke spread from a fire condition in the adjacent building. This was evidenced by the following:

90 minute fire rated horizontal exit doors were not arranged to be self-closing or automatic closing, as required.
1. The double set of 90 minute fire rated doors (between hospital and main clinic corridor) had the original self-closers removed. The doors are now equipped with a power operator that is also used for the self-closing function. The power operator was not arranged to have the door opener power supply disconnected upon fire alarm activation, as required. When tested during fire alarm activation, the power operator held the doors open for approximately 25 seconds before self-closing.
2. The single 90 minute door (between radiology and the waiting room) was equipped with a power operator that was not interconnected with the fire alarm system, as required. Horizontal exit fire doors that are held open must become self-closing upon activation of the fire alarm system.

Life Safety Code Section 18.2.2.2.6 requires that doors be held open only by an automatic release device that complies with Section 7.2.1.8.2. The fire alarm system, automatic sprinkler system (if provided) and the systems required by Section 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain the fire resistance rating of smoke barrier walls in accordance with the Life Safety Code Section 18-3.7.3. This deficient practice could affect all patients, staff and visitors within the east and west hospital smoke compartments by allowing the spread of fire and smoke to the adjoining compartment. This was evidenced by the following:

The one-hour fire rated smoke barrier wall (above ceiling at ED double doors from the sleeping room wing) did not have penetrations sealed to maintain the fire resistance rating of the wall, as required. The unsealed penetrations included:

1. Medical gas system pipe penetration with holes/voids in the fire caulk sealant.
2. 3 inch low voltage conduit (sleeve) with the internal fire caulking removed. This penetration must be evaluated for possible cable-overfill in accordance with the fire stop system manufacturer.
3. Low voltage sleeves (1 hour rated phone/data closet wall) had numerous sleeves that must be evaluated for possible cable-overfill in accordance with the fire stop system manufacturer.
4. A 1.5 inch flexible plastic conduit was observed to penetrate the one hour rated wall in two areas. The plastic conduit was not anchored into the wall framing and was not fire stopped at the penetrations. Unless specifically addressed by the fire stop system manufacturer, combustible cable penetrations cannot be fire stopped within the annular space around the penetration.

The above deficiencies were acknowledged by the Environmental Services Director during a tour of the facility.

Life Safety Code Section 8.3.6.1 requires, in part, that the space between the conduit/cable penetrations and the smoke barrier wall be filled with a material capable of maintaining the 1 hour fire/smoke resistance rating of the barrier.
Section A8.2.3.2.4.2: Penetrations through fire barriers by cables, wires, pipes, tubes, conduits, vents, and other penetrating items, as well as insulation and coverings on penetrating items, should meet one of the following criteria:
(1) They should be tested in accordance with NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials, as part of a rated assembly.
(2) They should be protected by an approved through-penetration system that has been tested in accordance with ASTM E 814, Methods for Fire Tests of Through-Penetration Fire Stops.
In lieu of A.8.2.3.2.4.2(1) or (2), the annular space around the penetrating item is permitted to be protected where the penetrating item is a cable or wire without a combustible jacket or where it is a noncombustible cable, wire, pipe, tube, conduit, or vent. The material used to fill the annular space, that is, spaces between a sleeve and a penetrating item and between a sleeve and a fire barrier, should prevent the passage of flame and hot gases that are sufficient to ignite cotton waste when subjected to the time-temperature fire conditions of NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. The test should be performed under a positive pressure differential of not less than 0.01 in. water column (2.5 Pa) at the location of the penetration for a time equivalent to the required fire resistance rating of the assembly penetrated. Where sleeves are used, the sleeves should be noncombustible and should be securely fastened to the fire barrier.

Based on observation and staff interview, it was determined that the facility failed to arrange and maintain doors in the means of egress in accordance with Life Safety Code Section 18.2.1 and Section 7-2. This deficient practice could affect all patients, staff and visitors within the facility, if code compliant exit doors are not provided for building egress.
This was evidenced by the following:

A) Egress doors were not maintained to provide the minimum design clearwidth, when open, as required. The urgent care entrance-outer sliding door was not fully opening. When opened by the power opener device, the door stopped prior to fully opening and provided a clearwidth opening of 31 inches.

B) Power operated sliding doors within the means of egress were not arranged to be readily opened from the egress side, as required. The urgent care entrance-inner sliding door, was equipped with a deadbolt style lock that voided the break-away feature of the door.

C) Doors in the means of egress were not equipped with code compliant access-controlled egress, in accordance with Section 7.1.6.2, as required. The double exit doors (patient sleeping compartment-east of the main nurse's station) were equipped with magnetic locks that were locked during the overnight hours. The magnetic locks would drop upon approach of an occupant via a motion sensor. The access-controlled egress system was deficient, as follows:
1. The doors were not equipped with Push to Exit release button in accordance with Section 7.2.1.6.2(c).

2. During activation of the building protective signaling system, the door failed to unlock in accordance with Section 7.2.1.6.2(d).

The means of egress deficiencies were acknowledged by the Environmental Services Director during a tour of the facility.

Life Safety Code Section 18.2.1 requires that means of egress components be arranged in accordance with Chapter 7. Section 7-2.1.5.1 requires that a door shall be so arranged as to be readily opened from the egress side whenever the building is occupied. Section 7.2.1.9.1 requires, in part, that powered doors be designed and installed so that when a force is applied to the door on the side from which egress is made, it shall be capable of swinging from any position to the full use of the required width of the opening in which it is installed (see 7.2.1.4).
Section 7.2.1.6.2 Access-Controlled Egress Doors:
Where permitted in Chapters 11 through 42, doors in the means of egress shall be permitted to be equipped with an approved entrance and egress access control system, provided that the following criteria are met.
(a) A sensor shall be provided on the egress side and arranged to detect an occupant approaching the doors, and the doors shall be arranged to unlock in the direction of egress upon detection of an approaching occupant or loss of power to the sensor.
(b) Loss of power to the part of the access control system that locks the doors shall automatically unlock the doors in the direction of egress.
(c) The doors shall be arranged to unlock in the direction of egress from a manual release device located 40 in. to 48 in. (102 cm to 122 cm) vertically above the floor and within 5 ft (1.5 m) of the secured doors. The manual release device shall be readily accessible and clearly identified by a sign that reads as follows: PUSH TO EXIT
When operated, the manual release device shall result in direct interruption of power to the lock - independent of the access control system electronics - and the doors shall remain unlocked for not less than 30 seconds.
(d) Activation of the building fire-protective signaling system, if provided, shall automatically unlock the doors in the direction of egress, and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.
(e) Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the doors in the direction of egress and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.

Based on record review and staff interview during the survey, it was determined that the facility failed to maintain a complete plan for the protection of all persons in the event of fire in accordance with Life Safety Code Section 18.7.1 and 18.7.2. This deficient practice could affect all patients if the facility policies are not current and staff response during a fire situation does not include knowledge and training in evacuation of the smoke compartment.
This was evidenced by the following:

The facility did not have an accurate and complete plan for the protection of all persons in the event of fire, as required. A review of policies and procedures within the Safety Manual documented the following:

A) The Fire Prevention Policy & Procedure, revision date 03-28-02, did not discuss the evacuation of a smoke compartment, as required. Policy document had not been updated to reflect the layout of the new building, constructed in 2007. Page 3 of 4 in the policy references medical gas shut off valves in the basement. The new facility is 1 story without a basement level.

B) The Fire Exit Layouts Policy, approved on 03-20-02, did not reflect the current one story facility, occupied in 2007. Page 2 of 2 discusses posted layouts and describes specific locations in the basement.

C) Employees were not periodically instructed and kept informed with respect to their duties under the plan, as required. The Environmental Services Director reported that new employee orientation was conducted using a training video and that there were no other periodic staff in-service training sessions discussing fire emergencies, other than critiques after fire drills and a semi- annual safety walk where staff were are questioned about the R.A.C.E and P.A.S.S policies.

Life Safety Code Section 18.7.1.1 requires that the administration of all health care facilities develop a plan for the protection of all persons in the event of fire, including a plan for their evacuation to an area of refuge and from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan.
The plan must include all components and requirements outlined in Life Safety Code Section 18.7.1 and 18.7.2.
Life Safety Code Section 18.7.2.2 requires that a written health care occupancy fire safety plan provide for the following:
1. Use of alarms
2. Transmission of alarms to the fire department
3. Response to alarms
4. Isolation of fire
5. Evacuation of immediate area
6. Evacuation of smoke compartment
7. Preparation of floors and building for evacuation
8. Extinguishment of fire
The facility has numerous sets of cross-corridor doors that are not part of a smoke barrier wall. Cross-corridor doors that are not part of a continuous smoke barrier wall assembly must be labeled as not being a smoke/fire barrier. Staff must be trained on the concepts of smoke compartments and use of the compartmented spaces as areas of refuge during internal evacuation/relocation of residents. Staff must also be trained on the facility door labeling plan and the impact upon relocation decisions during a fire emergency.

Based on record review and staff interview during the survey, it was determined that the facility failed to conduct fire drills in accordance with Life Safety Code Section 18.7.1.2 and Section 4.7. This deficient practice could affect all patients when staff are not drilled in the emergency actions required during the unusual conditions that can occur in an actual emergency.
This was evidenced by the following:

A) Fire drills were not conducted at least quarterly on each shift, as required. Fire drill records on premises did not document any fire drills conducted on the second shift (5:00 pm to 5:00 am) during the first and second quarters of 2013.

B) Fire drills were not conducted at unexpected times and under varying conditions, as required. A review of fire drill records for the prior 12 month period documented the following drill times:

First Shift (5:00 am to 5:00 pm):
06/17/13 @ 9:00 am
03/04/13 @ 10:00 am
12/11/12 @ 11:00 am
09/20/12 @ 9:45 am

C) A coded announcement was not used as a substitute for audible alarms, as required. Fire drill records documented the following drill procedures during the second shift (5:00 pm to 5:00 am):
12/11/12 @ 9:00 pm "Table Talk-discussion of fire drill procedures.
09/20/12 @ 7:00 pm "Silent Drill" no fire alarm was sounded.
D) Fire drills were not conducted as supervised events and were not conducted in accordance with the facility written Fire Drill Preparation Policy, as required. First shift (5:00 am to 5:00 pm) fire drills, conducted during the first and second quarters of 2013, were not conducted as supervised events. The drills were noted as being conducted during the annual fire alarm test and quarterly waterflow alarm tests, conducted by the fire alarm contractor. Maintenance staff stated that the documented drills did not have staff supervision.
The facility Fire Drill Preparation policy, dated 03-21-08, page one states, in part:
1. Prepare fire drill checklists.
2. Give the checklists to strategic persons who will help to evaluate the fire drill.

The Life Safety Code, Section 18.7.1.2 requires that fire drills in health care occupancies include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills shall be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building
Life Safety Code Section 4.7.3 requires that the responsibility for planning and conduct of drills be assigned only to competent persons qualified to exercise leadership.

Based on observation and staff interview during the survey, it was determined that the facility failed to install the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, and NFPA 72, National Fire Alarm Code. This deficient practice could affect all patients and staff in critical care areas should the fire alarm system fail to notify staff in all areas of the building. This was evidenced by the following:

Audible notification appliances were not distributed to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy, as required. During a test of the fire alarm system, the audible/visual alarms were inadequate and could not be effectively heard or seen by inside both operating rooms and in the sub-sterile room. Neither operating room, or the sub-sterile room, were provided with visual notification appliances.

Life Safety Code Section 18.3.4.3.1: Occupant notification shall be accomplished automatically in accordance with Section 9.6.3. Exception: In lieu of audible alarm signals, visible alarm indicating appliances shall be permitted to be used in critical care areas.

Based on record review and staff interview during the survey, it was determined that the facility failed to maintain the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25. This deficient practice could affect all patients, staff and visitors should the automatic sprinkler system fail to operate as designed due to non-code compliant maintenance. This was evidenced by the following:

Sprinkler system water supply check valves were not internally inspected every 5 years, as required. The Environmental Services Director was not aware of any records to document the 5 year check valve inspection. The sprinkler system was installed in 2007.

NFPA 25 Section 9-4.2.1 requires that check valves be inspected internally every 5 years to verify that all components operate properly, move freely and are in good condition.

Based on observation and staff interview during the survey, it was determined that the facility failed to install medical gas storage areas in accordance with Life Safety Code Section 18.3.2.4 NFPA 99 and NFPA 50. This deficient practice could affect all patients and building occupants should a fire occur at the bulk storage site. This was evidenced by the following:

Bulk liquid oxygen outside storage sites were not in accordance with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites, as required. The following site deficiencies were observed at the exterior bulk oxygen installation site on the north side of the building.

A) Parked vehicles were not at least 10 feet distant from the bulk storage container, as required. Two parked vehicles were observed to be approximately 6ft. to 8 ft. from the container.

B) Buildings of wood frame construction were not located at a distance of 50 feet or greater from the bulk container, as required. The medical waste storage building (metal panels on wood framing) was 43 feet from the bulk container. The Environmental Services Director reported that the wood frame storage building had been constructed in 2011.

C) Solid materials, that burn rapidly, were not stored at least 50 feet from the bulk container, as required.
1. An open top roll-off style trash/waste dumpster was located in the loading dock area, adjacent to the bulk site. The container was observed to have a mix of trash in plastic bags and landscape waste. The container was measured to be 15 feet from the storage container.

2. The trunk of an evergreen tree was measured to be approximately 12 feet from the container with the tree branches extending to the site fencing, approximately 4 ft. from the bulk container.

The Environmental Services Director acknowledged the combustible storage and proximity to the bulk container during a tour of the facility.

NFPA 50 Section 2-2 - Distance between Bulk Oxygen Systems and Exposures.
Except as provided in 2-2.14, the minimum distance from any bulk oxygen storage container to exposures, measured in the most direct line (except as indicated in 2-2.5 and 2-2.11), shall be as indicated in 2-2.1 to 2-2.14 inclusive.
Section 2-2.1: 50 feet from buildings of wood frame construction.
Section 2-2.7: 50 feet from solid materials that burn rapidly, such as excelsior or paper.
Section 2-2.12: 10 feet from any public sidewalk or parked vehicles.

A) Based on observation, staff interview and record review during the course of the survey, it was determined that the facility failed to install and test environmental in accordance with National Fire Protection Association Standard 99, Health Care Facilities. This deficient practice could affect patients and staff within the O/R during a fire/smoke condition should the system not automatically detect smoke and exhaust smoke while preventing recirculation.
This was evidenced by the following:

Supply and exhaust systems in O/R #1 and #2 were not arranged to vent smoke and were not arranged to prevent the recirculation of smoke, as required. The smoke evacuation system was tested in O/R #1 during the survey as follows:
1) With all fire alarm and HVAC systems normal, the ceiling smoke detector was activated in O/R #1. The damper on the O/R #1 exhaust system opened. Per the automated building monitoring system, the return fan on RTU-3 remained on and VAV #64 did not close (O/R#1 supply air). There was no noticeable increase in the speed of EF#7 for the O/R smoke exhaust. O/R #1 room pressure readings remained positive relative to the suite corridor. As arranged, the room was not negative to exhaust smoke and products of combustion and RTU-3 would potentially re-circulate smoke due to the return fan remaining on and no known damper movement at the unit.

2) While the system was still in the original alarm mode (as described in item 1 above) a smoke detector was activated outside O/R#1 in the suite corridor. This resulted in no change in the operation of RTU-3 or EF#7. O/R#1 remained under positive pressure. It is believed that GRH-1 operated to provide exhausting of the suite corridor.
Note: when the fire alarm system was reset, after the two activations described above, O/R#1 did go to negative pressure for approximately 3 minutes before resuming normal positive pressure.
The Environmental Services Director acknowledged the sequence of operation during and after the smoke evacuation test.
NFPA 99 Section 5-4.1.2: Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion. Section 5-4.1.3: Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.

B) Based on record review and staff interview during the course of the survey, it was determined that the facility failed to test anesthetizing location electrical systems in accordance with National Fire Protection Association Standard 99, Health Care Facilities. This deficient practice could affect patients and staff within the O/R should the ground-fault monitoring system not function as designed. This was evidenced by the following:

The line isolation monitor systems, installed in Operating Rooms #1 and #2, were not tested in accordance with NFPA 99 Section 3-3.3.4.2, as required. Facility records documented annual testing of the line isolation systems by an outside vendor in accordance with NFPA 99 Section 3-3.3.4.2.
The Environmental Services Director stated that there were no other tests of the line isolation monitors since August 2012.

NFPA 99 Section 3-3.3.4.2 Line Isolation Monitor Tests:
The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.

Based on record review and staff interview during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems. This deficient practice could affect all patients should the essential electrical system not function as designed due to lack of maintenance and testing. This was evidenced by the following:

The diesel powered emergency generator was not being load tested monthly at a minimum of 30% of nameplate rating, and was not exercised annually with supplemental loads, as required.
The 800 KW, 480v 3ph genset was exercised under load monthly with the available building load (all three ATS transferred monthly). Ampere readings were not recorded during the monthly tests. During the 07-03-13 generator annual service the technician conducted a load test with all three ATS transferred. Ampere readings were recorded as follows:
L1: 92 amps
L2: 134 amps
L3: 128 amps
30% on nameplate rating for the 800 KW genset would be approximately 288 amps. Available building load is significantly less than the required 30% minimum. There were no records of exhaust gas temperature readings during the monthly load tests.
There were no records on premises that documented generator testing with supplemental loads for a period of 2 hours in accordance with NFPA 110 Section 6-4.2. The Environmental Services Director confirmed that the generator had not been tested using supplemental loads (load bank testing).

NFPA 110 Section 6-4.2: Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
Section 6-4.2.2: Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain the two-hour fire rated separation to the clinic occupancy in accordance with Life Safety Code Section 18.1.2.1. This deficient practice could affect all patients, staff and visitors within the health care building should heat and smoke spread from a fire condition in the adjacent building. This was evidenced by the following:

Wall penetrations were not sealed to maintain the two-hour fire rating of the wall assembly, as required. The two hour wall (above the double 90 minute doors to the main clinic corridor) was observed to have a 3" x 3" hole in both layers of the gypsum board. The unsealed opening had a 110 volt armored cable through the opening.

A facility Maintenance Staff member acknowledged the penetration during a tour of the facility.

Life Safety Code Section 18.1.2.1 requires, in part, that sections of health care facilities that are classified as other occupancies be separated by two hour rated construction. Section 8-2.3.2.4 requires, in part, that penetrations and miscellaneous openings in fire barrier walls be filled with a material capable of maintaining the fire resistance rating of the barrier.

Based on observation during the survey, it was determined that the facility failed to install corridor doors in accordance with Life Safety Code Section 18.3.6.3.2. This deficient practice could affect all patients, staff and visitors within the patient sleeping wing smoke compartment should the egress corridor become untenable, due to smoke and heat transfer, via the non-latching corridor doors separating rooms from the egress corridor. This was evidenced by the following:

Corridor doors were not equipped with positive latching hardware, as required. The sliding doors on Observation Rooms #1 and #2 were not equipped with positive latching hardware.
Life Safety Code Section 18.3.6.3.2 (Corridor Doors): Doors shall be provided with positive latching hardware. Roller latches shall be prohibited.

Based on observation and staff interview during the survey, it was determined that the facility failed to arrange horizontal exit door release in accordance with the Life Safety Code Section 18-2.2.2.6 and 7.2.1.8.2. This deficient practice could affect all patients, staff and visitors within the health care building should heat and smoke spread from a fire condition in the adjacent building. This was evidenced by the following:

90 minute fire rated horizontal exit doors were not arranged to be self-closing or automatic closing, as required.
1. The double set of 90 minute fire rated doors (between hospital and main clinic corridor) had the original self-closers removed. The doors are now equipped with a power operator that is also used for the self-closing function. The power operator was not arranged to have the door opener power supply disconnected upon fire alarm activation, as required. When tested during fire alarm activation, the power operator held the doors open for approximately 25 seconds before self-closing.
2. The single 90 minute door (between radiology and the waiting room) was equipped with a power operator that was not interconnected with the fire alarm system, as required. Horizontal exit fire doors that are held open must become self-closing upon activation of the fire alarm system.

Life Safety Code Section 18.2.2.2.6 requires that doors be held open only by an automatic release device that complies with Section 7.2.1.8.2. The fire alarm system, automatic sprinkler system (if provided) and the systems required by Section 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain the fire resistance rating of smoke barrier walls in accordance with the Life Safety Code Section 18-3.7.3. This deficient practice could affect all patients, staff and visitors within the east and west hospital smoke compartments by allowing the spread of fire and smoke to the adjoining compartment. This was evidenced by the following:

The one-hour fire rated smoke barrier wall (above ceiling at ED double doors from the sleeping room wing) did not have penetrations sealed to maintain the fire resistance rating of the wall, as required. The unsealed penetrations included:

1. Medical gas system pipe penetration with holes/voids in the fire caulk sealant.
2. 3 inch low voltage conduit (sleeve) with the internal fire caulking removed. This penetration must be evaluated for possible cable-overfill in accordance with the fire stop system manufacturer.
3. Low voltage sleeves (1 hour rated phone/data closet wall) had numerous sleeves that must be evaluated for possible cable-overfill in accordance with the fire stop system manufacturer.
4. A 1.5 inch flexible plastic conduit was observed to penetrate the one hour rated wall in two areas. The plastic conduit was not anchored into the wall framing and was not fire stopped at the penetrations. Unless specifically addressed by the fire stop system manufacturer, combustible cable penetrations cannot be fire stopped within the annular space around the penetration.

The above deficiencies were acknowledged by the Environmental Services Director during a tour of the facility.

Life Safety Code Section 8.3.6.1 requires, in part, that the space between the conduit/cable penetrations and the smoke barrier wall be filled with a material capable of maintaining the 1 hour fire/smoke resistance rating of the barrier.
Section A8.2.3.2.4.2: Penetrations through fire barriers by cables, wires, pipes, tubes, conduits, vents, and other penetrating items, as well as insulation and coverings on penetrating items, should meet one of the following criteria:
(1) They should be tested in accordance with NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials, as part of a rated assembly.
(2) They should be protected by an approved through-penetration system that has been tested in accordance with ASTM E 814, Methods for Fire Tests of Through-Penetration Fire Stops.
In lieu of A.8.2.3.2.4.2(1) or (2), the annular space around the penetrating item is permitted to be protected where the penetrating item is a cable or wire without a combustible jacket or where it is a noncombustible cable, wire, pipe, tube, conduit, or vent. The material used to fill the annular space, that is, spaces between a sleeve and a penetrating item and between a sleeve and a fire barrier, should prevent the passage of flame and hot gases that are sufficient to ignite cotton waste when subjected to the time-temperature fire conditions of NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. The test should be performed under a positive pressure differential of not less than 0.01 in. water column (2.5 Pa) at the location of the penetration for a time equivalent to the required fire resistance rating of the assembly penetrated. Where sleeves are used, the sleeves should be noncombustible and should be securely fastened to the fire barrier.

Based on observation and staff interview, it was determined that the facility failed to arrange and maintain doors in the means of egress in accordance with Life Safety Code Section 18.2.1 and Section 7-2. This deficient practice could affect all patients, staff and visitors within the facility, if code compliant exit doors are not provided for building egress.
This was evidenced by the following:

A) Egress doors were not maintained to provide the minimum design clearwidth, when open, as required. The urgent care entrance-outer sliding door was not fully opening. When opened by the power opener device, the door stopped prior to fully opening and provided a clearwidth opening of 31 inches.

B) Power operated sliding doors within the means of egress were not arranged to be readily opened from the egress side, as required. The urgent care entrance-inner sliding door, was equipped with a deadbolt style lock that voided the break-away feature of the door.

C) Doors in the means of egress were not equipped with code compliant access-controlled egress, in accordance with Section 7.1.6.2, as required. The double exit doors (patient sleeping compartment-east of the main nurse's station) were equipped with magnetic locks that were locked during the overnight hours. The magnetic locks would drop upon approach of an occupant via a motion sensor. The access-controlled egress system was deficient, as follows:
1. The doors were not equipped with Push to Exit release button in accordance with Section 7.2.1.6.2(c).

2. During activation of the building protective signaling system, the door failed to unlock in accordance with Section 7.2.1.6.2(d).

The means of egress deficiencies were acknowledged by the Environmental Services Director during a tour of the facility.

Life Safety Code Section 18.2.1 requires that means of egress components be arranged in accordance with Chapter 7. Section 7-2.1.5.1 requires that a door shall be so arranged as to be readily opened from the egress side whenever the building is occupied. Section 7.2.1.9.1 requires, in part, that powered doors be designed and installed so that when a force is applied to the door on the side from which egress is made, it shall be capable of swinging from any position to the full use of the required width of the opening in which it is installed (see 7.2.1.4).
Section 7.2.1.6.2 Access-Controlled Egress Doors:
Where permitted in Chapters 11 through 42, doors in the means of egress shall be permitted to be equipped with an approved entrance and egress access control system, provided that the following criteria are met.
(a) A sensor shall be provided on the egress side and arranged to detect an occupant approaching the doors, and the doors shall be arranged to unlock in the direction of egress upon detection of an approaching occupant or loss of power to the sensor.
(b) Loss of power to the part of the access control system that locks the doors shall automatically unlock the doors in the direction of egress.
(c) The doors shall be arranged to unlock in the direction of egress from a manual release device located 40 in. to 48 in. (102 cm to 122 cm) vertically above the floor and within 5 ft (1.5 m) of the secured doors. The manual release device shall be readily accessible and clearly identified by a sign that reads as follows: PUSH TO EXIT
When operated, the manual release device shall result in direct interruption of power to the lock - independent of the access control system electronics - and the doors shall remain unlocked for not less than 30 seconds.
(d) Activation of the building fire-protective signaling system, if provided, shall automatically unlock the doors in the direction of egress, and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.
(e) Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the doors in the direction of egress and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.

Based on record review and staff interview during the survey, it was determined that the facility failed to maintain a complete plan for the protection of all persons in the event of fire in accordance with Life Safety Code Section 18.7.1 and 18.7.2. This deficient practice could affect all patients if the facility policies are not current and staff response during a fire situation does not include knowledge and training in evacuation of the smoke compartment.
This was evidenced by the following:

The facility did not have an accurate and complete plan for the protection of all persons in the event of fire, as required. A review of policies and procedures within the Safety Manual documented the following:

A) The Fire Prevention Policy & Procedure, revision date 03-28-02, did not discuss the evacuation of a smoke compartment, as required. Policy document had not been updated to reflect the layout of the new building, constructed in 2007. Page 3 of 4 in the policy references medical gas shut off valves in the basement. The new facility is 1 story without a basement level.

B) The Fire Exit Layouts Policy, approved on 03-20-02, did not reflect the current one story facility, occupied in 2007. Page 2 of 2 discusses posted layouts and describes specific locations in the basement.

C) Employees were not periodically instructed and kept informed with respect to their duties under the plan, as required. The Environmental Services Director reported that new employee orientation was conducted using a training video and that there were no other periodic staff in-service training sessions discussing fire emergencies, other than critiques after fire drills and a semi- annual safety walk where staff were are questioned about the R.A.C.E and P.A.S.S policies.

Life Safety Code Section 18.7.1.1 requires that the administration of all health care facilities develop a plan for the protection of all persons in the event of fire, including a plan for their evacuation to an area of refuge and from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan.
The plan must include all components and requirements outlined in Life Safety Code Section 18.7.1 and 18.7.2.
Life Safety Code Section 18.7.2.2 requires that a written health care occupancy fire safety plan provide for the following:
1. Use of alarms
2. Transmission of alarms to the fire department
3. Response to alarms
4. Isolation of fire
5. Evacuation of immediate area
6. Evacuation of smoke compartment
7. Preparation of floors and building for evacuation
8. Extinguishment of fire
The facility has numerous sets of cross-corridor doors that are not part of a smoke barrier wall. Cross-corridor doors that are not part of a continuous smoke barrier wall assembly must be labeled as not being a smoke/fire barrier. Staff must be trained on the concepts of smoke compartments and use of the compartmented spaces as areas of refuge during internal evacuation/relocation of residents. Staff must also be trained on the facility door labeling plan and the impact upon relocation decisions during a fire emergency.

Based on record review and staff interview during the survey, it was determined that the facility failed to conduct fire drills in accordance with Life Safety Code Section 18.7.1.2 and Section 4.7. This deficient practice could affect all patients when staff are not drilled in the emergency actions required during the unusual conditions that can occur in an actual emergency.
This was evidenced by the following:

A) Fire drills were not conducted at least quarterly on each shift, as required. Fire drill records on premises did not document any fire drills conducted on the second shift (5:00 pm to 5:00 am) during the first and second quarters of 2013.

B) Fire drills were not conducted at unexpected times and under varying conditions, as required. A review of fire drill records for the prior 12 month period documented the following drill times:

First Shift (5:00 am to 5:00 pm):
06/17/13 @ 9:00 am
03/04/13 @ 10:00 am
12/11/12 @ 11:00 am
09/20/12 @ 9:45 am

C) A coded announcement was not used as a substitute for audible alarms, as required. Fire drill records documented the following drill procedures during the second shift (5:00 pm to 5:00 am):
12/11/12 @ 9:00 pm "Table Talk-discussion of fire drill procedures.
09/20/12 @ 7:00 pm "Silent Drill" no fire alarm was sounded.
D) Fire drills were not conducted as supervised events and were not conducted in accordance with the facility written Fire Drill Preparation Policy, as required. First shift (5:00 am to 5:00 pm) fire drills, conducted during the first and second quarters of 2013, were not conducted as supervised events. The drills were noted as being conducted during the annual fire alarm test and quarterly waterflow alarm tests, conducted by the fire alarm contractor. Maintenance staff stated that the documented drills did not have staff supervision.
The facility Fire Drill Preparation policy, dated 03-21-08, page one states, in part:
1. Prepare fire drill checklists.
2. Give the checklists to strategic persons who will help to evaluate the fire drill.

The Life Safety Code, Section 18.7.1.2 requires that fire drills in health care occupancies include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills shall be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building
Life Safety Code Section 4.7.3 requires that the responsibility for planning and conduct of drills be assigned only to competent persons qualified to exercise leadership.

Based on observation and staff interview during the survey, it was determined that the facility failed to install the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, and NFPA 72, National Fire Alarm Code. This deficient practice could affect all patients and staff in critical care areas should the fire alarm system fail to notify staff in all areas of the building. This was evidenced by the following:

Audible notification appliances were not distributed to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy, as required. During a test of the fire alarm system, the audible/visual alarms were inadequate and could not be effectively heard or seen by inside both operating rooms and in the sub-sterile room. Neither operating room, or the sub-sterile room, were provided with visual notification appliances.

Life Safety Code Section 18.3.4.3.1: Occupant notification shall be accomplished automatically in accordance with Section 9.6.3. Exception: In lieu of audible alarm signals, visible alarm indicating appliances shall be permitted to be used in critical care areas.

Based on record review and staff interview during the survey, it was determined that the facility failed to maintain the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25. This deficient practice could affect all patients, staff and visitors should the automatic sprinkler system fail to operate as designed due to non-code compliant maintenance. This was evidenced by the following:

Sprinkler system water supply check valves were not internally inspected every 5 years, as required. The Environmental Services Director was not aware of any records to document the 5 year check valve inspection. The sprinkler system was installed in 2007.

NFPA 25 Section 9-4.2.1 requires that check valves be inspected internally every 5 years to verify that all components operate properly, move freely and are in good condition.

Based on observation and staff interview during the survey, it was determined that the facility failed to install medical gas storage areas in accordance with Life Safety Code Section 18.3.2.4 NFPA 99 and NFPA 50. This deficient practice could affect all patients and building occupants should a fire occur at the bulk storage site. This was evidenced by the following:

Bulk liquid oxygen outside storage sites were not in accordance with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites, as required. The following site deficiencies were observed at the exterior bulk oxygen installation site on the north side of the building.

A) Parked vehicles were not at least 10 feet distant from the bulk storage container, as required. Two parked vehicles were observed to be approximately 6ft. to 8 ft. from the container.

B) Buildings of wood frame construction were not located at a distance of 50 feet or greater from the bulk container, as required. The medical waste storage building (metal panels on wood framing) was 43 feet from the bulk container. The Environmental Services Director reported that the wood frame storage building had been constructed in 2011.

C) Solid materials, that burn rapidly, were not stored at least 50 feet from the bulk container, as required.
1. An open top roll-off style trash/waste dumpster was located in the loading dock area, adjacent to the bulk site. The container was observed to have a mix of trash in plastic bags and landscape waste. The container was measured to be 15 feet from the storage container.

2. The trunk of an evergreen tree was measured to be approximately 12 feet from the container with the tree branches extending to the site fencing, approximately 4 ft. from the bulk container.

The Environmental Services Director acknowledged the combustible storage and proximity to the bulk container during a tour of the facility.

NFPA 50 Section 2-2 - Distance between Bulk Oxygen Systems and Exposures.
Except as provided in 2-2.14, the minimum distance from any bulk oxygen storage container to exposures, measured in the most direct line (except as indicated in 2-2.5 and 2-2.11), shall be as indicated in 2-2.1 to 2-2.14 inclusive.
Section 2-2.1: 50 feet from buildings of wood frame construction.
Section 2-2.7: 50 feet from solid materials that burn rapidly, such as excelsior or paper.
Section 2-2.12: 10 feet from any public sidewalk or parked vehicles.

A) Based on observation, staff interview and record review during the course of the survey, it was determined that the facility failed to install and test environmental in accordance with National Fire Protection Association Standard 99, Health Care Facilities. This deficient practice could affect patients and staff within the O/R during a fire/smoke condition should the system not automatically detect smoke and exhaust smoke while preventing recirculation.
This was evidenced by the following:

Supply and exhaust systems in O/R #1 and #2 were not arranged to vent smoke and were not arranged to prevent the recirculation of smoke, as required. The smoke evacuation system was tested in O/R #1 during the survey as follows:
1) With all fire alarm and HVAC systems normal, the ceiling smoke detector was activated in O/R #1. The damper on the O/R #1 exhaust system opened. Per the automated building monitoring system, the return fan on RTU-3 remained on and VAV #64 did not close (O/R#1 supply air). There was no noticeable increase in the speed of EF#7 for the O/R smoke exhaust. O/R #1 room pressure readings remained positive relative to the suite corridor. As arranged, the room was not negative to exhaust smoke and products of combustion and RTU-3 would potentially re-circulate smoke due to the return fan remaining on and no known damper movement at the unit.

2) While the system was still in the original alarm mode (as described in item 1 above) a smoke detector was activated outside O/R#1 in the suite corridor. This resulted in no change in the operation of RTU-3 or EF#7. O/R#1 remained under positive pressure. It is believed that GRH-1 operated to provide exhausting of the suite corridor.
Note: when the fire alarm system was reset, after the two activations described above, O/R#1 did go to negative pressure for approximately 3 minutes before resuming normal positive pressure.
The Environmental Services Director acknowledged the sequence of operation during and after the smoke evacuation test.
NFPA 99 Section 5-4.1.2: Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion. Section 5-4.1.3: Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.

B) Based on record review and staff interview during the course of the survey, it was determined that the facility failed to test anesthetizing location electrical systems in accordance with National Fire Protection Association Standard 99, Health Care Facilities. This deficient practice could affect patients and staff within the O/R should the ground-fault monitoring system not function as designed. This was evidenced by the following:

The line isolation monitor systems, installed in Operating Rooms #1 and #2, were not tested in accordance with NFPA 99 Section 3-3.3.4.2, as required. Facility records documented annual testing of the line isolation systems by an outside vendor in accordance with NFPA 99 Section 3-3.3.4.2.
The Environmental Services Director stated that there were no other tests of the line isolation monitors since August 2012.

NFPA 99 Section 3-3.3.4.2 Line Isolation Monitor Tests:
The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.

Based on record review and staff interview during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems. This deficient practice could affect all patients should the essential electrical system not function as designed due to lack of maintenance and testing. This was evidenced by the following:

The diesel powered emergency generator was not being load tested monthly at a minimum of 30% of nameplate rating, and was not exercised annually with supplemental loads, as required.
The 800 KW, 480v 3ph genset was exercised under load monthly with the available building load (all three ATS transferred monthly). Ampere readings were not recorded during the monthly tests. During the 07-03-13 generator annual service the technician conducted a load test with all three ATS transferred. Ampere readings were recorded as follows:
L1: 92 amps
L2: 134 amps
L3: 128 amps
30% on nameplate rating for the 800 KW genset would be approximately 288 amps. Available building load is significantly less than the required 30% minimum. There were no records of exhaust gas temperature readings during the monthly load tests.
There were no records on premises that documented generator testing with supplemental loads for a period of 2 hours in accordance with NFPA 110 Section 6-4.2. The Environmental Services Director confirmed that the generator had not been tested using supplemental loads (load bank testing).

NFPA 110 Section 6-4.2: Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
Section 6-4.2.2: Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.