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Based on the life safety code post survey revisit conducted on 09/28/16 through 10/03/16 for the validation survey exited on 06/23/16, the facility failed to ensure the building construction was arranged and maintained to ensure the safety of the patients for the diagnosis and treatment and for special hospital services appropriate to the needs of the community as evidenced by the facility failure to ensure that; corridors were separated from use areas by walls constructed with at least 1/2 hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the passage of smoke, that ventilation shafts were maintained with the identified fire resistance rating as required in the code at 8.2.5., that smoke barriers were constructed to provide at least a one half hour fire resistance rating and constructed in accordance with 8.3., that one hour fire rated construction (with 3/4 hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous area , that heating and air conditioning complied with the provisions of section 9.2 and were installed in accordance with the manufacturer's specifications with regard to smoke and/or fire dampers and that medical gas storage and administration areas were protected in accordance with NFPA 99, Standard for Health Care Facilities and that oxygen storage locations of less than 3,000 cu.ft. were enclosed in accordance with storage requirements addressed in NFPA 99 (A 710). The cumulative effect of these systemic practices resulted in the agency's inability to ensure patient safety. The facility had a census of 140 patients.

Based on review of the facility schematic, tour of the facility, review of facility documentation and staff interview, the facility failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association. Potentially all patients and visitors could be adversely affected. The facility had a census of 140 patients.

Findings include:

On 09/28/16 through 10/03/16, a life safety code post survey revisit was conducted. Observations throughout the facility and in a the sampled selection of offsite locations were completed and the following findings are cited:

K17, which addressed the facility failure to ensure corridors were separated from use areas by walls constructed with at least 1/2 hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the passage of smoke.

K 20, the facility failed to ensure stairways, elevator shafts, and ventilation shafts maintained the identified fire resistance rating as required in the code at 8.2.5.

K 25, the facility failed to ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating and constructed in accordance with 8.3.

K 29, the facility failed to ensure that one hour fire rated construction (with 3/4 hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas.

K 67, the facility failed to ensure that heating, ventilating, and air conditioning complied with the provisions of section 9.2 and were installed in accordance with the manufacturer's specifications.

K 76, the facility failed to ensure that medical gas storage and administration areas were protected in accordance with NFPA 99, Standard for Health Care Facilities. That oxygen storage locations of less than 3,000 cu.ft. were enclosed in accordance with NFPA 99.

Please see the Life Safety Code report for more specific details.