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Based on observations and confirmed by staff, the facility failed to ensure that doors held open by magnetic devices release according to NFPA 72.

Section 7.2.1.8.2 states in any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, door leaves shall be permitted to be automatic-closing, provided that all of the following criteria are met:
(1) Upon release of the hold-open mechanism, the leaf becomes self-closing.
(2) The release device is designed so that the leaf instantly releases manually and, upon release, becomes selfclosing, or the leaf can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door leaf release service in NFPA 72, National Fire Alarm and Signaling Code.
(4) Upon loss of power to the hold-open device, the hold open mechanism is released and the door leaf becomes self-closing.
(5) The release by means of smoke detection of one door leaf in a stair enclosure results in closing all door leaves serving that stair.

NFPA 72 section 17.7.5.6.1 states smoke detectors that are part of an open area protection system covering the room, corridor, or enclosed space on each side of the smoke door and that are located and spaced as required by 17.7.3 shall be permitted to accomplish smoke door release service.

Section 17.7.3.2.3.1 states in the absence of specific performance-based design criteria, smooth ceiling smoke detector spacing shall be a nominal 30 ft (9.1 m).

Section 17.7.5.6.2 states smoke detectors that are used exclusively for smoke door release service shall be located and spaced as required by 17.7.5.6.

Section 17.7.5.6.3 states where smoke door release is accomplished directly from the smoke detector(s), the detector(s) shall be listed for releasing service.

Section 17.7.5.6.4 states smoke detectors shall be of the photoelectric, ionization, or other approved type.

Section 17.7.5.6.5 states the number of detectors required shall be determined in accordance with 17.7.5.6.5.1 through 17.7.5.6.5.4.

Section 17.7.5.6.5.1 states if doors are to be closed in response to smoke flowing in either direction, the requirements of 17.7.5.6.5.1(A) through 17.7.5.6.5.1(D) shall apply.
(A) If the depth of wall section above the door is 24 in. (610 mm) or less, one ceiling-mounted smoke detector shall be required on one side of the doorway only, or two wall-mounted detectors shall be required, one on each side of the doorway. Figure 17.7.5.6.5.1(A), part A or B, shall apply.
(B) If the depth of wall section above the door is greater than 24 in. (610 mm) on one side only, one ceiling-mounted smoke detector shall be required on the higher side of the doorway only, or one wall-mounted detector shall be required on both sides of the doorway. Figure 17.7.5.6.5.1(A), part D, shall apply.
(C)* If the depth of wall section above the door is greater than 24 in. (610 mm) on both sides, two ceiling-mounted or wall mounted detectors shall be required, one on each side of the doorway. Figure 17.7.5.6.5.1(A), part F, shall apply.
(D) If a detector is specifically listed for door frame mounting, or if a listed combination or integral detector-door closer assembly is used, only one detector shall be required if installed
in the manner recommended by the manufacturer's published instructions. Figure 17.7.5.6.5.1(A), parts A, C, and E, shall apply.

FIGURE 17.7.5.6.5.1(A) Detector Location Requirements for Wall Sections indicates that a smoke detector is required within 5' of the door opening on one side where the depth of the wall above the door opening is less than 24" on each side of the doorway.

THE FINDINGS INCLUDE:

During the afternoon hours of 12/12/16 at approximately 2:00 P.M. while surveying the 5th floor of the Lahey Building, the separation door leading into the Converse Building was observed to be in the open position. Upon closer examination, the door was observed to be held open by a magnetic hold open device wired to the facility's fire alarm system.
However, the closest smoke detector for door release was observed to be approximately 38' from the actual door opening. Because of the corridor smoke detection exceeding 30' in spacing, a smoke detector is required within 5' of the door opening.

As a result of the smoke detector configuration and the door being held open by a magnetic device, the facility failed to comply with section 17.7.5.6.5.1 for proper smoke detection devices.

This finding was confirmed by the Facility's Management Staff during the exit interview conference.

Based on observations and confirmed by staff, the facility failed to ensure that required means of egress from the 2nd floor Operating Room area was in compliance with Section 7.2.

Section 7.2.2.3.3.1 states stair treads and landings shall be solid, without perforations, unless otherwise permitted in 7.2.2.3.3.4.

Section 7.2.2.3.3.4 states the requirement of 7.2.2.3.3.1 shall not apply to noncombustible grated stair treads and landings in the following occupancies:
(1) Assembly occupancies as otherwise provided in Chapters 12 and 13
(2) Detention and correctional occupancies as otherwise provided in Chapters 22 and 23
(3) Industrial occupancies as otherwise provided in Chapter 40
(4) Storage occupancies as otherwise provided in Chapter 42

THE FINDINGS INCLUDE:Observations during a tour of the facility on 12/14/16 revealed the required exit located off the 2nd floor in the rear of the Operating Room area, by OR #17, did not meet the requirements of Section 7.2.2.3.3.1 as the landing and treads of the exterior stairs were constructed with perforations.

As a result of the perforated treads and landing, the facility failed to comply with section 7.2.2.3.3.1.

This finding was confirmed by the Facility's Management Staff during the exit interview conference.

Based on observations and confirmed by staff, the facility failed to ensure that horizontal exits are maintained as required.

Section 19.2.2.5 states horizontal exits complying with 7.2.4 and the modifications of 19.2.2.5.1 through 19.2.2.5.4 shall be permitted.

Section 7.2.4.3.1 states fire barriers separating buildings or areas between which there are horizontal exits shall have a minimum 2-hour fire resistance rating, unless otherwise provided in 7.2.4.4.1, and shall provide a separation that is continuous to the finished ground level.

THE FINDINGS INCLUDE:

During the afternoon hours of 12/13/16 at approximately 3:45 P.M. while surveying the 2nd floor of the Lahey Building, the horizontal exit wall leading into the Old Main Building was viewed for structural integrity. The wall was observed to have an approximate 6" x 12" unsealed penetration directly above the set of fire doors.

As a result of the wall penetration, the facility failed to comply with section 7.2.4.3.1 requiring a 2-hour separation between buildings.

This finding was confirmed by the Facility's Management Staff during the exit interview conference.

Based on observations and confirmed by staff, the facility failed to ensure that two approved egress routes from each compartment are provided as required.

Section 19.2.4.1 states the number of means of egress shall be in accordance with 7.4.1.1 and 7.4.1.3 through 7.4.1.6.

Section 19.2.4.4 states not less than two exits shall be accessible from each smoke compartment, and egress shall be permitted through an adjacent compartment(s), provided that the two required egress paths are arranged so that both do not pass through the
same adjacent smoke compartment.

Section 19.2.6.2.1 states the travel distance between any point in a room and an exit shall not exceed 150 ft (46 m), unless otherwise permitted by 19.2.6.2.2.

Section 19.2.6.2.2 states the maximum travel distance specified in 19.2.6.2.1 shall be permitted to be increased by 50 ft (15 m) in buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7.

Section 7.7.2 states exits shall be permitted to discharge through interior building areas, provided that all of the following are met:

(1) Not more than 50 percent of the required number of exits, and not more than 50 percent of the required egress capacity, shall discharge through areas on any level of discharge, except as otherwise permitted by one of the following:
(a) One hundred percent of the exits shall be permitted to discharge through areas on any level of discharge in detention and correctional occupancies as otherwise provided in Chapters 22 and 23.
(b) In existing buildings, the 50 percent limit on egress capacity shall not apply if the 50 percent limit on the required number of exits is met.

(2) Each level of discharge shall discharge directly outside at the finished ground level or discharge directly outside and provide access to the finished ground level by outside stairs or outside ramps.

(3) The interior exit discharge shall lead to a free and unobstructed way to the exterior of the building, and such way shall be readily visible and identifiable from the point of discharge from the exit.

(4) The interior exit discharge shall be protected by one of the following methods:
(a) The level of discharge shall be protected throughout by an approved automatic sprinkler system in accordance with Section 9.7, or the portion of the level of discharge used for interior exit discharge shall be protected by an approved automatic sprinkler system
in accordance with Section 9.7 and shall be separated from the non-sprinklered portion of the floor by fire barriers with a fire resistance rating meeting the requirements for the enclosure of exits. (See 7.1.3.2.1.)
(b) The interior exit discharge area shall be in a vestibule or foyer that meets all of the following criteria:
i. The depth from the exterior of the building shall be not more than 10 ft (3050 mm), and the
length shall be not more than 30 ft (9.1 m).
ii. The foyer shall be separated from the remainder of the level of discharge by construction
providing protection not less than the equivalent of wired glass in steel frames or 45 minutes
fire-resistive construction.
iii. The foyer shall serve only as means of egress and shall include an exit directly to the outside.

(5) The entire area on the level of discharge shall be separated from areas below by construction having a fire resistance rating not less than that required for the exit enclosure,
unless otherwise provided in 7.7.2(6).

(6) Levels below the level of discharge in an atrium shall be permitted to be open to the level of discharge where such level of discharge is protected in accordance with 8.6.7.

THE FINDINGS INCLUDE:

During the survey period between 12/12/16 and 12/15/16, it was observed that the Jenk's East Building was not equipped with two approved means of egress. The second exit from this building utilizes stairwell "A" of the Jenk's Building. Stairwell "A" terminates into the 3rd floor level corridor and not directly to the outside as required. The 3rd floor level is not considered fully sprinklered nor is the exit foyer separated from the non-sprinklered area by a 45-minute fire resistance rating.

Note: Stairwell "A" of the Lahey Building is considered the second exit from this unit because allowable travel distances are exceeded in all other egress routes provided.

As a result, the facility failed to ensure that two approved egress routes were provided as required by 19.2.4.4.

This finding was confirmed by the Facility's Management Staff during the exit interview conference.

Based on observations and confirmed by staff, the facility failed to ensure that egress routes are constructed as required.

Section 7.7.1 states exits shall terminate directly at a public way or at an exterior exit discharge, unless otherwise provided in 7.7.1.2 through 7.7.1.4.

Section 7.7.1.1 states yards, courts, open spaces, or other portions of the exit discharge shall be of the required width and size to provide all occupants with a safe access to a public way.

THE FINDINGS INCLUDE:

During the survey period between 12/12/16 and 12/15/16, it was observed that exterior egress routes with hard packed surfaces are not provided in all areas of the hospital.

The following stairwells are not equipped with a hard packed walkway to ensure the means of egress is always free of obstructions that would prevent its use, such as ice, sleet, snow and the need for its removal in climates such as the Northeast region.
:
1) Stairwell "A" in the Jenk's Building (This stairwell leads to a courtyard which in turn leads to a grass covered sloped lawn)

2) Stairwell "A" in the Lahey Building (This stairwell leads to a courtyard which in turn leads to a grass covered sloped lawn)

3) Stairwell "A" in the Converse Building (This stairwell leads to a grass covered sloped lawn)

4) Stairwell "B" in the Converse Building (This stairwell leads to a grass covered sloped lawn)

As a result, the facility failed to comply with 7.7.1.1 requiring hard packed walkways to a public way.

This finding was confirmed by the Facility's Management Staff during the exit interview conference.

Based on observations and confirmed by staff, the facility failed to ensure that egress illumination is continuous during occupancy.

Section 7.8.1.1 states illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 43. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way.

Section 7.8.1.2 states illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use, unless otherwise provided in 7.8.1.2.2.

Section 7.8.1.3 states the floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated in 7.8.1.1 shall be illuminated as follows:
(1) During conditions of stair use, the minimum illumination for new stairs shall be at least 10 ft-candle (108 lux), measured at the walking surfaces.
(2) The minimum illumination for floors and walking surfaces, other than new stairs during conditions of stair use, shall be to values of at least 1 ft-candle (10.8 lux), measured at the
floor.
(3) In assembly occupancies, the illumination of the walking surfaces of exit access shall be at least 0.2 ft-candle (2.2 lux) during periods of performances or projections involving directed
light.
(4)*The minimum illumination requirements shall not apply where operations or processes require low lighting levels.

THE FINDINGS INCLUDE:

During the survey period between 12/12/16 and 12/15/16, it was observed that the majority of the hospital corridors were equipped with manually operated light switches located on the corridor walls. When these light switches were tested for operation, the corridors were observed to be left in complete darkness without any egress lighting. As stated, this applies to numerous locations throughout the entire facility.

As a result of the current configuration of light switches located on corridor walls, the egress illumination is capable of being shut off in its' entirety and failing to comply with section 7.8.1.2.

This finding was confirmed by the Facility's Management Staff during the exit interview conference.

Based on observations, the facility failed to ensure that hazardous areas are enclosed as required.

Section 19.3.2.1 Hazardous Areas states any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1.

Section 19.3.2.1.1 states an automatic extinguishing system, where used in hazardous areas, shall be permitted to be in accordance with 19.3.5.9.

Section 19.3.2.1.2 states where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4.

THE FINDINGS INCLUDE:

Observations while touring the facility on 12/14/16 revealed that the 20 minute Firelite rated glass window in the pass through leading from the 3rd floor Operating Room core to the Implant Room did not self close to maintain the Implant Room smoke tight. Note: The Implant Room has been classified as a hazardous area as a result of the storage of combustible supplies.

As a result of the deficiency, the facility failed to maintain compliance with section 19.3.2.1.2

The findings were confirmed by facility management staff during the exit conference.

Based on observations, confirmed by documentation review and staff interview the facility failed to ensure compliance with the following sections of 2009 edition of NFPA 17A Standard for Wet Chemical Extinguishing Systems.

-Section 7.2.1 On a monthly basis, inspection shall be conducted in
accordance with the manufacturer's listed installation and
maintenance manual or the owner's manual.

-Section 7.2.2 At a minimum, this "quick check" or inspection shall include verification of the following:
(1) The extinguishing system is in its proper location.
(2) The manual actuators are unobstructed.
3) The tamper indicators and seals are intact.
(4) The maintenance tag or certificate is in place.
(5) No obvious physical damage or condition exists that
might prevent operation.
(6) The pressure gauge(s), if provided, shall be inspected
physically or electronically to ensure it is in the operable
range.
(7) The nozzle blowoff caps, where provided, are intact and
undamaged.
(8) Neither the protected equipment nor the hazard has not
been replaced, modified, or relocated.

-Section 7.2.3 If any deficiencies are found, appropriate corrective
action shall be taken immediately.

-Section 7.2.3.1 Where the corrective action involves maintenance, it shall be conducted by a service technician as outlined in 7.3.1.

-Section 7.2.4 Personnel making inspections shall keep records for
those extinguishing systems that were found to require corrective
actions.

-Section 7.2.5 At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded.

-Section 7.2.6 The records shall be retained for the period between
the semiannual maintenance inspections.

Findings Include:

While conducting an inspection of the facility's third floor cafeteria and second floor main kitchen, on the afternoon of 12/14/16, it was observed that the inspection tags affixed to the manual actuators of both systems were not being initialed in acknowledgment of the performance of a required monthly inspection. When questioned the facility's life safety consultant and representatives of the maintenance staff stated that they were unaware of the requirement.

As a result of the finding the facility is found to be non-compliant with Section 7.2.1 and Section 7.2.2 of NFPA 17A.

The findings were confirmed by facility management staff during the exit conference.

Based on record review, the facility failed to maintain records of the required tests for the back-up batteries to the fire alarm system.

NFPA 101, Section 19.3.4.1 General states health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

Section 9.6.1.3 states a fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

NFPA 72, 2010 edition, Table 14.4.5 requires systems with sealed batteries to replace the battery every 5 years, have the battery charger tested annually, conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually.

THE FINDINGS INCLUDE:

Record review conducted on 12/12-15/16 of the vendor inspection/test forms dated 12/14/15, 9/12-14/16, 6/6-9/16, and 3/7-10/16, revealed that the documentation does not indicate the specific required tests of the fire alarm batteries in accordance with NFPA 72.

In addition, upon inspection of the batteries it was determined that the batteries providing back up power to the main panel, located above the ceiling in the Security Office, were dated 6/9/10. The installation date of the batteries located in the Jenks Building and Pump House could not be determined. Intervew with the vendor confirmed that the installation date of the batteries in Jenks Building and Pump House was unknown. The vendor also stated that testing of the batteries has not been conducted under their contract.

As a result, the facility was not in compliance with NFPA 72, Table 14.4.5 which requires systems with sealed batteries to be replaced every 5 years, to have the battery charger tested annually, conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually.

The findings were confirmed by facility management staff during the exit conference.

Based on record review and confirmed by staff, it was revealed that the facility failed to ensure the fire alarm system was maintained as required. NFPA 101, Section 19.3.4.1 General states Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

NFPA 101, Section 9.6.1.3 states a fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

NFPA 72, Section 14.1.1 states the inspection, testing, and maintenance of systems, their initiating devices, and notification appliances shall comply with the requirements of this chapter.

NFPA 72 National Fire Alarm and Signaling Code section 14.2.2.1 states the property or building or system owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system.

NFPA 72, Section 14.2.2.2 states the delegation of responsibility shall be in writing,with a copy of such delegation provided to the authority having jurisdiction upon request.

Section 14.6.2.4 states a record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in
Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested
(8) Functional test of detectors
(9)*Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification systems
(14) Functional test of ability of mass notification system to silence fire alarm notification appliances
(15) Tests of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer ' s published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device abandoned in place)

NFPA 72, Table 14.4.5 section 6.(d) Testing Frequencies requires sealed lead acid fire alarm batteries to have a 30 minute annual discharge test, a semi-annual load voltage test conducted, and to be replaced every 5 years. Table 14.4.5 section 15. (k) requires pressure supervisory devices and other suppression system supervisory initiating devices to be tested quarterly and valve supervisory switches and waterflow devices to be tested semi-annually.

THE FINDINGS INCLUDE:

A review of the provided documentation of the fire alarm system testing and inspection was conducted between 12/12/16 and 12/15/16. The only report provided for review was dated 2/19/16. As a result of this review, the following items were revealed:

Battery testing on the 2/19/16 vendor inspection report failed to indicate any testing was conducted on the Fire Alarm Control Panel's batteries. Therefore, the facility failed to be in compliance with NFPA 72, Table 14.4.5 as documentation was not provided to substantiate an annual 30 minute battery discharge test or the semi-annual load voltage test.

In addition, the batteries are dated 2/1/11 and 4/16/10 and therefore, both sets of batteries are over the 5 year age limit.

As a result of the findings, the facility was not in compliance with NFPA 72.

The findings were confirmed by facility management staff during survey and at the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that sprinkler systems are properly maintained as required.

Section 39.1.1.3 states the provisions of Chapter 4, General, shall apply.

Section 4.1.1 states a goal of this code is to provide an environment for the occupants that is reasonably safe from fire by the following means:
(1)*Protection of occupants not intimate with the initial fire development.
(2) Improvement of the survivability of occupants intimate with the initial fire development.

Section 4.2.3 states systems utilized to achieve the goals of Section 4.1 shall be effective in mitigating the hazard or condition for which they are being used, shall be reliable, shall be maintained to the level at which they were designed to operate, and shall remain operational.

Section 4.6.12.4 states any device, equipment, system, condition, arrangement, level of protection, fire resistive construction or any other feature requiring periodic testing, inspection or operation to ensure its maintenance shall be tested, inspected or operated as specified elsewhere in this code or directed by the authority having jurisdiction.

NFPA #25 (Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems) section 4.1.1 states the property owner or designated representative shall be responsible for properly maintaining a water based fire protection system.

Section 4.1.1.1.1 states inspection, testing, maintenance, and impairment shall be implemented in accordance with procedures meeting those established in this document and in accordance with the manufacturer ' s instructions.

Section 4.1.1.2 states inspection, testing, and maintenance shall be performed by personnel who have developed competence through training and experience.

Section 4.1.4.1 states the property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by this standard.

Section 4.1.4.2 states corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.

Section 4.5.1 states all components and systems shall be tested to verify that they function as intended.

Release # 01-201 from Central Sprinkler Corporation announced a voluntary replacement program of recalled sprinkler heads. Central manufactured 33 million "wet" sprinklers with O-rings from 1989 until 2000 that are effected by this recall. The fire sprinkler heads have the words "CENTRAL" or "STAR", the letters "CSC", the letter "G" in triangle, or a star-shaped symbol stamped on either the metal sprinkler frame or on the deflector. The model designation and date may also be stamped on the frame or deflector. The deflector is the flower, or gear-shaped metal piece at one end of the sprinkler head.
Section 5.3.3.1 states mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly.

Section 5.3.3.3 states testing waterflow alarm devices on wet pipe systems shall be accomplished by opening the inspector's test connection.

THE FINDINGS INCLUDE:

During the morning hours of 12/15/16 at approximately 10:30 A.M., the following items were observed regarding the sprinkler system:

1) An approximate total of 20 sprinkler heads were observed as being on the national list of recalled heads. The sprinkler heads observed were "1992 Central GB" heads. These heads were observed in the main gym area of the suite.

2) The sprinkler system was observed to be tested/inspected on an annual basis only. The last documented inspection/test was performed on 3/7/16. As noted above, various components are required to have quarterly testing performed.

As a result of the above findings, the facility failed to comply with section 39.1.1.3 requiring systems to be maintained in a proper operating condition.

This finding was confirmed by the Facility's Management Staff during the exit interview conference.

Based on observations and confirmed by staff interview the facility failed to ensure compliancy with the following sections of the 2011 edition of NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

-Section 5.3.1.1.1.6 states that dry sprinklers that have been in service for 10 years shall be replaced or representative samples shall be tested and then retested at 10-year intervals.

-Section 5.2.1.1.1 states sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).

-Section 5.3.3.1 states mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly.

- Section 5.3.3.2 states vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually.

- Section 5.3.3.3 states testing waterflow alarm devices on wet pipe systems shall be accomplished by opening the inspector ' s test connection.

- Section 13.4.4.2 refers to Testing for Dry Pipe Valves/Quick-Opening Devices.
13.4.4.2.1 The priming water level shall be tested quarterly.
13.4.4.2.2 Each dry pipe valve shall be trip tested annually during warm weather.
13.4.4.2.2.1 Dry pipe valves protecting freezers shall be trip tested in a manner that does not introduce moisture into the piping in the freezers.
13.4.4.2.2.2 Every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully open and the quick-opening device, if provided, in service.
13.4.4.2.2.3 During those years when full flow testing in accordance with 13.4.4.2.2.2 is not required, each dry pipe valve shall be trip tested with the control valve partially open.
13.4.4.2.3 Grease or other sealing materials shall not be applied to the seating surfaces of dry pipe valves.
13.4.4.2.4 Quick-opening devices, if provided, shall be tested quarterly.
13.4.4.2.5 A tag or card that shows the date on which the dry pipe valve was last tripped, and the name of the person and organization conducting the test, shall be attached to the valve.
13.4.4.2.5.1 Separate records of initial air and water pressure, tripping air pressure, and dry pipe valve operating conditions shall be maintained on the premises for comparison with previous test results.
13.4.4.2.5.2 Records of tripping time shall be maintained for full flow trip tests.
13.4.4.2.6 Low air pressure alarms, if provided, shall be tested quarterly in accordance with the manufacturer ' s instructions.
13.4.4.2.7 Low temperature alarms, if installed in valve enclosures, shall be tested annually at the beginning of the heating season.
13.4.4.2.8 Automatic air pressure maintenance devices, if provided, shall be tested annually during the dry pipe valve trip test in accordance with the manufacturer ' s instructions.
13.4.4.2.9 Dry pipe systems shall be tested once every 3 years for air leakage, using one of the following test methods:
(1)A pressure test at 40 psi (3.2 bar) shall be performed for 2 hours.
(a)The system shall be permitted to lose up to 3 psi (0.2 bar) during the duration of the test.
(b)Air leaks shall be addressed if the system loses more than 3 psi (0.2 bar) during this test.
(2)With the system at normal system pressure, the air source (compressor or shop air) shall be shut off for 4 hours. If the low air pressure alarm goes off within this period, the air leaks shall be addressed.

13.4.4.3 Maintenance.
13.4.4.3.1 During the annual trip test, the interior of the dry pipe valve shall be cleaned thoroughly, and parts replaced or repaired as necessary.
13.4.4.3.2 Auxiliary drains in dry pipe sprinkler systems shall be drained after each operation of the system, before the onset of freezing weather conditions, and thereafter as needed.

THE FINDINGS INCLUDE:

1. While conducting the facility tour during the afternoon hours of 12/14/16 observations revealed that the covers of the dry recessed sprinkler heads located within the main kitchen's six (6)walk-in coolers/freezers were sealed to the ceilings with silicone caulking thereby creating an impediment to the covers ability to freely drop away and allow the sprinkler to perform as designed.

In addition an interview of maintenance staff relevant to the age of the dry sprinklers proved them to be in excess of ten (10) years old.

As a result of the findings the facility is found to be non-compliant with Section 5.3.1.1.1.6 and Section 5.2.1.1.1 of NFPA 25.

2. While reviewing sprinkler system vendor reports dated 1/21/16, 4/7/16, 7/15/16, and 10/24/16 it was revealed that some water flow switches located in the Converse Building were tested manually as it was necessary to run hoses to conduct a test of the water flow devices when opening the inspector's test connection. The vendor report dated 10/24/16 for the Converse Building states "Some flows are tested manually to prevent potential hazards of installing garden hoses."

As as result, the facility failed to test the waterflow alarm devices on wet pipe systems by opening the inspector ' s test connection in accordance with NFPA 25, Section 5.3.3.3.

3. While reviewing sprinkler system vendor reports dated 1/21/16, 4/7/16, 7/15/16, and 10/24/16 it was revealed that the testing and inspection of the dry valves were not under contract by the current vendor. As a result, there was no documenation available to substantiate any testing or maintenance of the dry type system located in the Jenks Mechanical room.

As a result, the facility failed to test and maintain the dry sprinkler system in accordance with NFPA 25, Sections 13.4.4.2 and 13.4.4.3.

Note: The proposed contract dated 15-NOV-16 does include testing of the dry sprinkler system.

The findings were confirmed by facility management staff during the exit conference.

Based on observations and documentation review the facility failed to ensure compliancy with required NFPA (National Fire Protection Association) regulations.

-Section 21.7.6 "Maintenance and Testing" of Chapter 21 "Existing Ambulatory Health Care Occupancies" of the 2012 edition of NFPA 101 "Life safety Code" requires compliance with Chapter 4 "General" Section 4.6.12.4.

-Section 4.6.12.4 states the following: Any device, equipment, system, condition, arrangement, level of protection, fire resistive construction or any other feature requiring periodic testing, inspection or operation to ensure its maintenance shall be tested, inspected or operated as specified elsewhere in this code or directed by the authority having jurisdiction.

-Section 7.1.1.2 of the 2010 edition of NFPA 13 "Standard For The Installation of Sprinkler Systems" states pressure gages shall be installed above and below each alarm check valve or system riser check valve where such devices are present.

-Section 5.2.4.1 of the 2011 edition of NFPA 25 "Standard For The Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems" states that gages on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.

THE FINDINGS INCLUDE:

A review of the facility's sprinkler inspection documentation and a facility tour conducted on the morning of 12/14/16 resulted in the following.

1. There was no documentation substantiating the monthly inspection of the wet pipe system's pressure gages.

2. There was no pressure gage installed on the supply side of the backflow
preventer. The backflow preventer is a check valve which allows water to pass through in one direction locking the water pressure on the system (house) side of the device. If the municipal supply pressure were to be lost or reduced it would not be indicated on the system side gages. A pressure gauge must be installed on the supply side of the backflow preventer in order to accurately monitor the municipal water supply pressure.

As a result of the findings the facility was found to be non-compliant with NFPA 13 Section 7.1.1.2 and NFPA 25 Section 5.2.4.1.

The findings were confirmed by facility management staff during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure compliance with Chapter 19 Section 19.3.6.1 of the 2012 edition of NFPA 101 "Life Safety Code" .

NFPA 101 Chapter 19 Section 19.3.6.1 "Corridor Separation" sub-section (7) states spaces, other than patient sleeping rooms, treatment rooms, and hazardous areas, shall be permitted to be open to the corridor and unlimited in area, provided that all of the following criteria are met:

(a) The space and the corridors onto which it opens, where located in the same smoke compartment, are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4.
(b)Each space is protected by automatic sprinklers, or the furnishings and furniture, in combination with all other combustibles within the area, are of such minimum quantity and arrangement that a fully developed fire is unlikely to occur.
(c) The space does not obstruct access to required exits.

The Findings Include:

While conducting the facility tour during the afternoon hours of 12/12/16, observations revealed the wheel chair room, located across from the information desk in the front lobby, was open to the corridor and was not equipped with an electrically supervised automatic smoke detector.

As a result of the finding the facility is found to be non-compliant with criteria (1)(c) of NFPA 101 Chapter 19 Section 19.3.6.1.

Note: This particular space is not arranged and located so as to allow direct supervision by the facility staff on a 24 hour basis.

The findings were confirmed by facility management staff during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure compliance with Chapter 19 Section 19.3.6.2.7 of the 2012 edition of NFPA 101 "Life Safety Code".

Section 19.3.6.2.7 states fixed fire window assemblies in accordance with Section 8.3 shall be permitted in corridor walls, unless otherwise permitted in 19.3.6.2.8.

Section 19.3.6.2.8 states there shall be no restrictions in area and fire resistance of glass and frames in smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7.

THE FINDINGS INCLUDE:

Observations throughout the duration of the survey revealed an opening in the corridor wall leading to the ambulance check-in. The opening consisted of a 23" x 45.5" sliding plain glass vision panel with two fixed windows on each side. This window assembly did not meet the requirements of Chapter 19 Section 19.3.6.2.7 or Section 19.3.6.2.8 and as a result, is non-compliant.

The findings were confirmed by facility management staff during the exit conference.

Based on observations and confirmed by staff the facility failed to ensure compliance with Chapter 19 "Existing Health Care Occupancies" of the 2012 edition of NFPA 101 "Life Safety Code".

Chapter 19 "Existing Health Care Occupancies", Section 19.3.6.3 "Corridor Doors", Sub-Section 19.3.6.3.5 states that corridor doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.

THE FINDINGS INCLUDE:

During the morning hours of 12/13/16 at approximately 10:45 A.M. while surveying the 3rd floor of the Converse Building, it was observed that the rear door to Men's Locker Room has a broken latching mechanism. When the door was tested for operation, the latch was observed to be stuck in the retracted position keeping the door from achieving positive latching as required.

As a result of the finding the facility is found to be non-compliant with Chapter 19 Sub-Section 19.3.6.3.5.

This finding was confirmed by the Facility's Management Staff during the exit interview conference.

Based on observations and confirmed by staff, the facility failed to ensure that corridor doors are properly constructed as required.

Section 19.3.6.3.16 states fixed fire window assemblies in accordance with Section 8.3 shall be permitted in corridor doors.

Section 19.3.6.3.17 states restrictions in area and fire resistance of glass and frames required by Section 8.3 shall not apply in smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7.

Section 8.3.3.5 states fire protection-rated glazing shall be permitted in fire barriers having a required fire resistance rating of 1 hour or less and shall be of an approved type with the appropriate fire protection rating for the location in which the barriers are installed.

THE FINDINGS INCLUDE:

During the afternoon hours of 12/12/16 at approximately 3:45 P.M. while surveying the 4th floor of the Lahey Building, it was observed that the door to room #467 was equipped with an approximate 5" x 20" tempered glass vision panel. This particular smoke zone identified on the LSC drawings as SC-4E was not equipped with an automatic sprinkler system.

In addition, three of the four Pantries located on the 4th and fifth floors of the Jenks building were equipped with doors equipped with tempered glass vision panels. The Pantries were not protected by an automatic sprinkler system.

As a result of plain glass in a non-sprinklered compartment, the facility failed to comply with section 19.3.6.3.17.

This finding was confirmed by the Facility's Management Staff during the exit interview conference.

Based on observations and confirmed by staff, the facility failed to ensure compliance with Chapter 19 Sections 19.3.7.6 and 19.3.7.6.2 of the 2012 edition of NFPA 101 "Life Safety Code" .

NFPA 101 Chapter 19 Section 19.3.7.6 states openings in smoke barriers shall be protected using one of the following methods:
(1) Fire-rated glazing
(2) Wired glass panels in steel frames
(3) Doors, such as 1 3/4 in. (44 mm) thick, solid-bonded woodcore doors
(4) Construction that resists fire for a minimum of 20 minutes.
Section 19.3.7.6.2 states doors shall be permitted to have fixed fire window assemblies in accordance with Section 8.5.

The Findings Include:

While conducting the facility tour during the afternoon hours of 12/12/16, observations revealed the smoke barrier doors leading from the 3rd floor main lobby to the PACU/PRE-OP corridor are equipped with plain glass vision panels.

Note: These doors are identified as being part of the smoke barrier on the Third Floor Life Safety Plan dated 12/7/16 which were provided to the surveyors during the survey.

As a result of the finding the facility is found to be non-compliant with the criteria of NFPA 101 Chapter 19 Section 19.3.7.6.2.

The findings was confirmed by facility management staff during the exit conference.

Based on record review and confirmed by staff interview, the facility failed to conduct fire drills as required. NFPA 101 "Life Safety Code" (2012 edition) Chapter 39, section 39.7.2 Drills, states that in all business occupancy buildings occupied by more than 500 persons, or by more than 100 persons above or below the street level, employees and supervisory personnel shall be periodically instructed and shall hold drills periodically where practicable.

Findings Include:

A review conducted revealed that there are no documented fire drills conducted at the facility's 830 Boylston Street site.

As a result of the finding the facility is found to be non-compliant with NFPA 39, section 7.2

The findings were confirmed by facility management staff during the exit conference.

Based on observations, the facility failed to ensure that portable electric heaters were prohibited from use in patient acre areas. NFPA 101, Life Safety Code, section 19.7.8, Portable Space-Heating Devices states that portable space heating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:
(1) Such devices are used only in non-sleeping staff and employee areas, and
(2) The heating elements of such devices do not exceed 212°F (100°C).

FINDINGS INCLUDE:

Observations throughout the duration of the survey revealed that two portable space heating devices were utilized at the Jenk's Buildings' fifth floor west staff break room, six portable space heating devices were utilized at the fifth floor east nurses' station, and one portable space heating device was utilized in the operating room area implant storage room. All the devices were noted to be electric coil type portable space heating devices.

As a result, the facility failed to comply with the acceptable criteria provided in section 19.7.8

The findings were confirmed by facility management staff during survey and at the exit conference.

Based on observations and documentation review the facility failed to ensure compliancy with NFPA (National Fire Protection Association) regulations.

-Section 21.7.6 "Maintenance and Testing" of Chapter 21 "Existing Ambulatory Health Care Occupancies" of the 2012 edition of NFPA 101 "Life Safety Code" requires compliance with Chapter 4 "General" Section 4.6.12.

-Section 4.6.12.4 states the following: Any device, equipment, system, condition, arrangement, level of protection, fire resistive construction or any other feature requiring periodic testing, inspection or operation to ensure its maintenance shall be tested, inspected or operated as specified elsewhere in this code or directed by the authority having jurisdiction.

-Section 5.3.1 of the 2010 edition of NFPA 110 "Standard for Emergency Power Systems" states that the EPS shall be heated as necessary to maintain the water jacket and battery temperature determined by the EPS manufacturer for cold start and load acceptance for the type of EPSS.

-Section 7.3.1 of the 2010 edition of NFPA 110 "Standard for Emergency Power Systems" states that the Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures that do not include walk-in access.

-Section 8.3.5 of the 2010 edition of NFPA 110 "Standard for Emergency Power Systems" states transfer switches shall be subjected to a maintenance and testing program that includes all of the following operations:
(1) Checking of connections
(2) Inspection or testing for evidence of overheating and excessive contact erosion
(3) Removal of dust and dirt
(4) Replacement of contacts when required

Findings Include:

A review of the facility's Emergency Power System inspection documentation and an inspection of the EPS generator set conducted on the morning of 12/14/16 resulted in the following.

1. The generator set which is located outdoors in an enclosure which includes walk-in access was not equipped with battery heaters or battery-powered emergency lighting as required.

2. The Emergency Power Systems five (5) automatic transfer switches were not subjected to a maintenance and testing program that includes the operations as required by Section 8.3.5 of NFPA 110.

As a result of the finding the facility is found to be non-compliant with NFPA 110 Sections 5.3.1, 7.3.1 and 8.3.5.

The findings were confirmed by facility management staff during the exit conference.