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Unsealed openings/penetrations were observed in the fire walls as follows:

During the survey, the following is an example of what was observed:

Unsealed penetrations around a group of conduit in the two fire walls by the Lab Waiting Room.



8.2.2.2* Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.

8.2.3.2.4.2* Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:

(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:

a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.

(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:

a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.

(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:

a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.

(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:

a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

The facility failed to provide a permitted construction type required by code. Findings include:

During the survey, the following is an example of what was observed,

The single story part of the building is a Type II (000) and was observed not to have a complete automatic sprinkler system. The following areas did not have an automatic sprinkler system:

The front alcove, the Laboratory, and the Medical Records Storage Room (old Dietary).



2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
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The facility failed to provide corridor walls that would provide at least a 30 minute fire resistance rating. Findings include:

During the survey, the following are examples of what was observed:

Unsealed penetrations around two water lines, and behind a junction box in the corridor wall by Patient Room 141.



NFPA 101, 19.3.6.1 Corridors in unsprinklered smoke compartments shall be separated from all other areas by partitions having a fire resistance rating of at least 1/2 hour.

The facility failed to maintain the corridor openings per code. Findings include:

During the survey, the following are examples of what was observed:

1. The Soiled Equipment Room door failed to latch. This door opens into the corridor and room is located at the Elevator.

2. The door to the Nurses' Office failed to close tight as to resist the passage of smoke, this is a dutch style door opening into the corridor.


NFPA 101, 19.3.6.3.1 Exception No.2. In the smoke compartments protected throughout by an approved, supervised automatic sprinkler system, doors in corridor walls shall be constructed to resist the passage of smoke and be provided with suitable means of keeping the doors closed.


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3. The Pink Lady Storage Room did not have positive latching hardware.
4. The following corridor doors had door stops on them:

a. The Laboratory Waiting Room
b. The E.R. Discharge Area


2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. 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. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
2000 NFPA 101, 19.3.6.3.3 Hold-open devices that release when the door is pushed or pulled shall be permitted.
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The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include:

During the survey, the following are examples of what was observed:

1. Unsealed penetrations around a group of wiring in the Smoke Barrier by the Vending Machine Room.

2. Unsealed penetrations around a group of wiring by the duct in the Smoke Barrier by Patient Room 157.



NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

The facility failed to provide a reliable means of egress to the public way. Based upon observation during the survey, the following are examples of what was observed:

1. The Exit Discharge for the Exit by Patient Room 136 was not provided with an all weather surface to the public way.

2. The Exit Discharge for the Exit from Surgery was not provided with an all weather surface to the public way.


NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

NFPA 101, A.7.1.10.1 *A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

The facility failed to maintain the two hour fire barriers per code. Findings include:

During the survey, the following are examples of what was observed:

1. The two hour fire barrier in the Old Staff Dining Room had unsealed penetrations at the bar joists.

2. The Nurses' Lounge corridor door - across from Exam 2/Exam 3 is in a two hour fire barrier. The door was observed not to be an 1 1/2 hour fire rated door and did not have a self-closing device.


2000 NFPA 101, 8.2.2.2 Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.
2000 NFPA 101, 8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) * Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.
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The facility failed to maintain an exit sign per code. Findings include:

During the survey, the following is an example of what was observed:

The exit sign in C.T. was observed not to be illuminated.


2000 NFPA 101, 7.10.5.1 Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.
2000 NFPA 101, 7.10.5.2 Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.
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The facility failed to provide a written fire evacuation per code. Findings include:

During the survey, the following is an example of what was observed:

The facility could not provide a smoke compartment evacuation, the facility only had a total evacuation of the building.


2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to 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
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The facility failed to conduct fire drills under varying conditions at unexpected times. Findings include:

During the survey, the following are examples of what was observed:

1) Based upon observation of the documentation provided by the facility for the fire drills, the facility failed to conduct drills for the month of January 2011, February 2011 (first quarter 2011); January 2010, March 2010 (first quarter 2010); August 2010 (third quarter), and November 2010 (fourth quarter).


NFPA 101, 19.7.1.2 Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts to simulate the unusual conditions occurring in case of fire.



2) Based upon interview with the Plant Operations Director, all staff were not participating in the drills.


NFPA 101, 19.7.1.2 and 19.7.1.3 Drills shall include proper procedures, making sure all staff members participate.

The facility failed to provide complete/current documentation of the inspection of the fire alarm system. During the survey, the following are examples of what was observed:

Based upon observation of the documentation provided by the facility for the annual inspection of the Fire Alarm System on 3/16/2010, in the comment section, the alarm company noted that AHU #11 failed to shut down upon activation of the alarm. Also the manual pull station by the Nurses' Station failed to activate the fire alarm, and the horn/strobe by room B-6 did not function when alarm was activated. The Plant Operation Director advised this surveyor that all these problems were corrected, but he could not provide the documentation to indicate this.


1999 NFPA 72, 7-5.2.2 and Figure 7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be maintained which includes periodic tests and applicable information.

The facility failed to maintain the fire alarm system per code. Findings include:

During the survey, the following is an example of what was observed:

The smoke/fire doors reset when the fire alarm system was silenced.


Alabama Department of Public Health, Technical Services Unit Transmittal Dated 06/09/99.
The door hold-open magnets or devices must not return to their normal function until the alarm has been fully reset at the alarm panel.

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The facility failed to perform sensitivity testing of the smoke detectors. Findings include:

During the survey, the following are examples of what was observed:

Documentation was not provided by the facility for the biannual sensitivity testing of the smoke detectors.


Documentation provided by the facility, during the survey, did not indicate sensitivity testing of the smoke detectors. Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

Sprinkler coverage was observed, during the survey, not adequately provided. Findings include:

During the survey, the following are examples of what was observed:


1. Broken ceiling tile above the time clock.

2. Missing ceiling tiles in the Soiled Equipment Room in the Basement.

3. Broken ceiling tile in the Kitchen of the Out Patient Suite.

4. Missing ceiling tiles in the Surgery Supply Room.


NFPA 13, 5-6, Sprinklers shall be arranged to be in compliance.

The facility failed to perform the required maintenance of the facility sprinkler system. Findings include:

During the survey, the following is an example of what was observed:

1) Based upon documentation provided by the facility the quarterly inspections were conducted for the sprinkler systems on 3/1/2010, 5/9/2010, 8/20/2010; 2/28/2011. An inspection should have been conducted by the end of second week of December 2010.

NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).


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2) Based on observation, the sprinkler riser gauges were dated 1971. Documentation and an interview with the maintenance staff revealed the gauges had not been calibrated or replaced within the last five years.

1998 NFPA 25, 2-3.2 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.
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The facility failed to maintain the fire extinguishers per code. Findings include:

During the survey, the following is an example of what was observed:

The fire extinguishers throughout the facility were not inspected by the facility in August 2010.

1998 NFPA 10, 4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

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The facility failed to adequately perform testing and inspection of the dietary hood
extinguishment system. Findings include:

During the survey, the following is an example of what was observed:


The provided documentation for the monthly inspection of the hood system was
the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff. This side of the inspection card was blank.


NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or owner's manual. As a minimum, this "quick check" or inspection shall include verification of the following:

(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blow-off caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

The facility failed to maintain the draperies/curtains per code. Findings include:

During the survey, the following are examples of what was observed:

The following rooms were observed with valancies on which the facility could not provide flame resistant documentation:

1. The Administrator's Office
2. The Small Conference Room

2000 NFPA 101, 10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.
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The facility failed to maintain the piped medical gas system per code. Findings include:

During the survey, the facility could not provide medical gas documentation.

1999 NFPA 99, 4-3.5.2.3 Patient Gas Systems - Level 1.

(c) Maintenance programs in accordance with the manufacturers' recommendations shall be established for the medical air compressor supply system as connected in each individual installation.

(g) A periodic testing procedure for nonflammable medical gas and related alarm systems shall be implemented.

(h) The test specified in 4-3.4.1.3(i) shall be conducted on the downstream portions of the medical gas piping system whenever a system is breached or whenever modifications are made or maintenance performed.

(i) * Periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly, and records of the test shall be maintained until the next test.

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The facility failed to provide a generator per code. Findings include:

During the survey, the following is an example of what was observed:

Per interview with the maintenance staff the generator was installed in 1973 without a remote annunciator.

1971 NFPA 76A, 641 A remote annunciator, storage battery powered, shall be provided to operate outside of the Generating Room in a location readily observed by operating personnel at a regular work station, (see Section 700-12, NFPA N0. 70-1971.) Where a regular work station may be unattended periodically, an appropriately labeled derangement signal shall be exhibited at the telephone switchboard. The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate:
(1) When the emergency or auxiliary power source is operating to supply power to load.
(2) When the battery charger is malfunctioning.
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate:
(1) Low lubricating oil pressure.
(2) Low water temperature (below those required in 623).
(3) Excessive water temperature.
(4) Low fuel - when the main fuel storage tank contains less than a three-hour operating supply.
(5) Overcrank (failure to start).
(6) Overspeed.
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The facility failed to maintain the generator per code. Findings include:

During the survey, the following is an example of what was observed:

Per documentation and interview with the maintenance staff, the generator was not being tested under load monthly.

1999 NFPA 110, 6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
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The facility failed to provide a Type I Essential Electrical System (EES) per code. Findings include:

During the survey, the following is an example of what was observed:
Per administrative staff, this facility does performed general surgery that requires using electrical life support equipment. Based on observation and interview with the maintenance staff, the EES is a Type III.


1999 NFPA 99, 3-4.2.2.1 Type I essential electrical systems are comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective facility operation during the time the normal electrical service is interrupted for any reason. These two systems are the emergency system and the equipment system. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch. The equipment system shall supply major electrical equipment necessary for patient care and basic Type I operation. Both systems shall be arranged for connection, within time limits specified in this chapter, to an alternate source of power following a loss of the normal source. The number of transfer switches to be used shall be based upon reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA (120 kW).
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The facility failed to provide approved electrical utilities. Findings include:

During the survey, the following are examples of what was observed:


1. Two junction boxes were missing the covers above the ceiling at the two hour fire wall, inside the Nurses' Lounge.

2. A junction box was missing the cover above the ceiling by Patient Room 145.

3. A junction box was missing the cover above the ceiling at Stairwell One.

4. A junction box was missing the cover above the ceiling by Patient Room 158.

5. A junction box was missing the cover above the ceiling by the Rear Hall Fire Doors.

6. An extension cord was in use without the proper overcurrent protection in the Boiler Room.

1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.

1999 NFA 70, Article 240-4, and HFCA Transmittal Notice 22-99 prohibit the use of extension cords without overcurrent protection.


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7. Housekeeping - a refrigerator and microwave were plugged into a power strip.
8. Small Conference Room - a refrigerator was plugged into a power strip.

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

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The facility failed to provide the sprinkler system fire watch per code.

2000 NFPA 101, 9.7.6.1 Where required, if an automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

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The facility failed to provide a fire alarm system fire watch per code.


2000 NFPA 101, 9.6.1.8 Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.
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Unsealed openings/penetrations were observed in the fire walls as follows:

During the survey, the following is an example of what was observed:

Unsealed penetrations around a group of conduit in the two fire walls by the Lab Waiting Room.



8.2.2.2* Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.

8.2.3.2.4.2* Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:

(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:

a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.

(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:

a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.

(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:

a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.

(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:

a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

The facility failed to provide a permitted construction type required by code. Findings include:

During the survey, the following is an example of what was observed,

The single story part of the building is a Type II (000) and was observed not to have a complete automatic sprinkler system. The following areas did not have an automatic sprinkler system:

The front alcove, the Laboratory, and the Medical Records Storage Room (old Dietary).



2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
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The facility failed to provide corridor walls that would provide at least a 30 minute fire resistance rating. Findings include:

During the survey, the following are examples of what was observed:

Unsealed penetrations around two water lines, and behind a junction box in the corridor wall by Patient Room 141.



NFPA 101, 19.3.6.1 Corridors in unsprinklered smoke compartments shall be separated from all other areas by partitions having a fire resistance rating of at least 1/2 hour.

The facility failed to maintain the corridor openings per code. Findings include:

During the survey, the following are examples of what was observed:

1. The Soiled Equipment Room door failed to latch. This door opens into the corridor and room is located at the Elevator.

2. The door to the Nurses' Office failed to close tight as to resist the passage of smoke, this is a dutch style door opening into the corridor.


NFPA 101, 19.3.6.3.1 Exception No.2. In the smoke compartments protected throughout by an approved, supervised automatic sprinkler system, doors in corridor walls shall be constructed to resist the passage of smoke and be provided with suitable means of keeping the doors closed.


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3. The Pink Lady Storage Room did not have positive latching hardware.
4. The following corridor doors had door stops on them:

a. The Laboratory Waiting Room
b. The E.R. Discharge Area


2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. 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. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
2000 NFPA 101, 19.3.6.3.3 Hold-open devices that release when the door is pushed or pulled shall be permitted.
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The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include:

During the survey, the following are examples of what was observed:

1. Unsealed penetrations around a group of wiring in the Smoke Barrier by the Vending Machine Room.

2. Unsealed penetrations around a group of wiring by the duct in the Smoke Barrier by Patient Room 157.



NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

The facility failed to provide a reliable means of egress to the public way. Based upon observation during the survey, the following are examples of what was observed:

1. The Exit Discharge for the Exit by Patient Room 136 was not provided with an all weather surface to the public way.

2. The Exit Discharge for the Exit from Surgery was not provided with an all weather surface to the public way.


NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

NFPA 101, A.7.1.10.1 *A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

The facility failed to maintain the two hour fire barriers per code. Findings include:

During the survey, the following are examples of what was observed:

1. The two hour fire barrier in the Old Staff Dining Room had unsealed penetrations at the bar joists.

2. The Nurses' Lounge corridor door - across from Exam 2/Exam 3 is in a two hour fire barrier. The door was observed not to be an 1 1/2 hour fire rated door and did not have a self-closing device.


2000 NFPA 101, 8.2.2.2 Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.
2000 NFPA 101, 8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) * Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.
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The facility failed to maintain an exit sign per code. Findings include:

During the survey, the following is an example of what was observed:

The exit sign in C.T. was observed not to be illuminated.


2000 NFPA 101, 7.10.5.1 Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.
2000 NFPA 101, 7.10.5.2 Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.
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The facility failed to provide a written fire evacuation per code. Findings include:

During the survey, the following is an example of what was observed:

The facility could not provide a smoke compartment evacuation, the facility only had a total evacuation of the building.


2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to 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
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The facility failed to conduct fire drills under varying conditions at unexpected times. Findings include:

During the survey, the following are examples of what was observed:

1) Based upon observation of the documentation provided by the facility for the fire drills, the facility failed to conduct drills for the month of January 2011, February 2011 (first quarter 2011); January 2010, March 2010 (first quarter 2010); August 2010 (third quarter), and November 2010 (fourth quarter).


NFPA 101, 19.7.1.2 Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts to simulate the unusual conditions occurring in case of fire.



2) Based upon interview with the Plant Operations Director, all staff were not participating in the drills.


NFPA 101, 19.7.1.2 and 19.7.1.3 Drills shall include proper procedures, making sure all staff members participate.

The facility failed to provide complete/current documentation of the inspection of the fire alarm system. During the survey, the following are examples of what was observed:

Based upon observation of the documentation provided by the facility for the annual inspection of the Fire Alarm System on 3/16/2010, in the comment section, the alarm company noted that AHU #11 failed to shut down upon activation of the alarm. Also the manual pull station by the Nurses' Station failed to activate the fire alarm, and the horn/strobe by room B-6 did not function when alarm was activated. The Plant Operation Director advised this surveyor that all these problems were corrected, but he could not provide the documentation to indicate this.


1999 NFPA 72, 7-5.2.2 and Figure 7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be maintained which includes periodic tests and applicable information.

The facility failed to maintain the fire alarm system per code. Findings include:

During the survey, the following is an example of what was observed:

The smoke/fire doors reset when the fire alarm system was silenced.


Alabama Department of Public Health, Technical Services Unit Transmittal Dated 06/09/99.
The door hold-open magnets or devices must not return to their normal function until the alarm has been fully reset at the alarm panel.

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The facility failed to perform sensitivity testing of the smoke detectors. Findings include:

During the survey, the following are examples of what was observed:

Documentation was not provided by the facility for the biannual sensitivity testing of the smoke detectors.


Documentation provided by the facility, during the survey, did not indicate sensitivity testing of the smoke detectors. Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

Sprinkler coverage was observed, during the survey, not adequately provided. Findings include:

During the survey, the following are examples of what was observed:


1. Broken ceiling tile above the time clock.

2. Missing ceiling tiles in the Soiled Equipment Room in the Basement.

3. Broken ceiling tile in the Kitchen of the Out Patient Suite.

4. Missing ceiling tiles in the Surgery Supply Room.


NFPA 13, 5-6, Sprinklers shall be arranged to be in compliance.

The facility failed to perform the required maintenance of the facility sprinkler system. Findings include:

During the survey, the following is an example of what was observed:

1) Based upon documentation provided by the facility the quarterly inspections were conducted for the sprinkler systems on 3/1/2010, 5/9/2010, 8/20/2010; 2/28/2011. An inspection should have been conducted by the end of second week of December 2010.

NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).


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2) Based on observation, the sprinkler riser gauges were dated 1971. Documentation and an interview with the maintenance staff revealed the gauges had not been calibrated or replaced within the last five years.

1998 NFPA 25, 2-3.2 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.
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The facility failed to maintain the fire extinguishers per code. Findings include:

During the survey, the following is an example of what was observed:

The fire extinguishers throughout the facility were not inspected by the facility in August 2010.

1998 NFPA 10, 4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

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The facility failed to adequately perform testing and inspection of the dietary hood
extinguishment system. Findings include:

During the survey, the following is an example of what was observed:


The provided documentation for the monthly inspection of the hood system was
the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff. This side of the inspection card was blank.


NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or owner's manual. As a minimum, this "quick check" or inspection shall include verification of the following:

(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blow-off caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

The facility failed to maintain the draperies/curtains per code. Findings include:

During the survey, the following are examples of what was observed:

The following rooms were observed with valancies on which the facility could not provide flame resistant documentation:

1. The Administrator's Office
2. The Small Conference Room

2000 NFPA 101, 10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.
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The facility failed to maintain the piped medical gas system per code. Findings include:

During the survey, the facility could not provide medical gas documentation.

1999 NFPA 99, 4-3.5.2.3 Patient Gas Systems - Level 1.

(c) Maintenance programs in accordance with the manufacturers' recommendations shall be established for the medical air compressor supply system as connected in each individual installation.

(g) A periodic testing procedure for nonflammable medical gas and related alarm systems shall be implemented.

(h) The test specified in 4-3.4.1.3(i) shall be conducted on the downstream portions of the medical gas piping system whenever a system is breached or whenever modifications are made or maintenance performed.

(i) * Periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly, and records of the test shall be maintained until the next test.

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The facility failed to provide a generator per code. Findings include:

During the survey, the following is an example of what was observed:

Per interview with the maintenance staff the generator was installed in 1973 without a remote annunciator.

1971 NFPA 76A, 641 A remote annunciator, storage battery powered, shall be provided to operate outside of the Generating Room in a location readily observed by operating personnel at a regular work station, (see Section 700-12, NFPA N0. 70-1971.) Where a regular work station may be unattended periodically, an appropriately labeled derangement signal shall be exhibited at the telephone switchboard. The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate:
(1) When the emergency or auxiliary power source is operating to supply power to load.
(2) When the battery charger is malfunctioning.
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate:
(1) Low lubricating oil pressure.
(2) Low water temperature (below those required in 623).
(3) Excessive water temperature.
(4) Low fuel - when the main fuel storage tank contains less than a three-hour operating supply.
(5) Overcrank (failure to start).
(6) Overspeed.
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The facility failed to maintain the generator per code. Findings include:

During the survey, the following is an example of what was observed:

Per documentation and interview with the maintenance staff, the generator was not being tested under load monthly.

1999 NFPA 110, 6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
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The facility failed to provide a Type I Essential Electrical System (EES) per code. Findings include:

During the survey, the following is an example of what was observed:
Per administrative staff, this facility does performed general surgery that requires using electrical life support equipment. Based on observation and interview with the maintenance staff, the EES is a Type III.


1999 NFPA 99, 3-4.2.2.1 Type I essential electrical systems are comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective facility operation during the time the normal electrical service is interrupted for any reason. These two systems are the emergency system and the equipment system. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch. The equipment system shall supply major electrical equipment necessary for patient care and basic Type I operation. Both systems shall be arranged for connection, within time limits specified in this chapter, to an alternate source of power following a loss of the normal source. The number of transfer switches to be used shall be based upon reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA (120 kW).
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The facility failed to provide approved electrical utilities. Findings include:

During the survey, the following are examples of what was observed:


1. Two junction boxes were missing the covers above the ceiling at the two hour fire wall, inside the Nurses' Lounge.

2. A junction box was missing the cover above the ceiling by Patient Room 145.

3. A junction box was missing the cover above the ceiling at Stairwell One.

4. A junction box was missing the cover above the ceiling by Patient Room 158.

5. A junction box was missing the cover above the ceiling by the Rear Hall Fire Doors.

6. An extension cord was in use without the proper overcurrent protection in the Boiler Room.

1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.

1999 NFA 70, Article 240-4, and HFCA Transmittal Notice 22-99 prohibit the use of extension cords without overcurrent protection.


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7. Housekeeping - a refrigerator and microwave were plugged into a power strip.
8. Small Conference Room - a refrigerator was plugged into a power strip.

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

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The facility failed to provide the sprinkler system fire watch per code.

2000 NFPA 101, 9.7.6.1 Where required, if an automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

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The facility failed to provide a fire alarm system fire watch per code.


2000 NFPA 101, 9.6.1.8 Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.
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