HospitalInspections.org

Based on observations and confirmed by staff the Hospital failed to ensure that smoke barrier doors, which are permitted to be held open, are equipped with automatic releasing devices that are compliant with the requirements of the 2012 edition of NFPA 101 "Life Safety Code"

Section 19.2.2.2.7 states that any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2, shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

FINDINGS INCLUDE:

While conducting the life safety facility tour during the morning hours of 11/14/17 observations revealed the following.

The smoke barrier door identified as #3-177 is equipped with a self-closing device which has a manually operated hold open feature. The door is not equipped with a releasing device that would automatically close upon activation of the automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2,

As a result of the finding the facility is found to be non-compliant with Chapter 7 Section 7.2.1.8.2.

These findings were acknowledged by the Hospital's Administrative team during the exit interview.

Based on observation and confirmed by staff, the Hospital failed to ensure that the travel distance from a non-sleeping suite was compliant with the requirements of the 2012 edition of NFPA 101 "Life Safety Code"

-Section 19.2.5.7.3 states that patient care non-sleeping suites shall be in accordance with the following:
(1) Non-sleeping suites for patient care shall comply with the provisions of 19.2.5.7.3.1 through 19.2.5.7.3.4.

-Section 19.2.5.7.3.4 states the following:
(A) Travel distance within a non-sleeping suite to an exit access door from the suite shall not exceed 100 ft (30 m).
(B) Travel distance between any point in a non-sleeping suite and an exit shall not exceed the following:
(1) 150 ft (46 m) if the building is not protected throughout by an approved electrically supervised sprinkler system complying with 19.3.5.7
(2) 200 ft (61 m) if the building is protected throughout by an approved electrically supervised sprinkler system complying with 19.3.5.7

FINDINGS INCLUDE:

A facility tour conducted on the afternoon of 11/15/17 revealed that the travel distance from the furthest point in the non-sleeping Radiology suite to an exit exceeds the maximum allowable distance of 150 ft. for a building that is not fully protected throughout by an approved electrically supervised sprinkler system complying with 19.3.5.7.

Note: Building #02 (Lorusso) is classified and surveyed as a partially-sprinklered building.

As a result of the finding, the facility is found to be non-compliant with Chapter 19 Section 19.2.5.7.3.4

These findings were acknowledged by the Hospital's Administrative team during the exit interview.

Based on observations and confirmed by staff, the facility failed to ensure that all egress routes are compliant with the requirements of the 2012 edition of NFPA 101 "Life Safety Code" and CMS Survey and Certification Letter 05-38.

-CMS Survey and Certification Letter 05-38 requires that the exit discharge shall be a hard packed all-weather travel surface suitable for the climatic conditions of the region.

-Chapter 7 Section 7.1.7.1 states changes in level in means of egress shall be achieved by an approved means of egress where the elevation difference exceeds 21 in. (535 mm.)

-Chapter 7 Section 7.1.7.2 states changes in level in means of egress not in excess of 21 in. (535 mm) shall be achieved either by a ramp complying with the requirements of 7.2.5 or by a stair complying with the requirements of 7.2.2.

-Chapter 7 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.

FINDINGS INCLUDE:

A facility tour conducted on the afternoon of 11/15/17 revealed that the "A" stairwell which connects the third, second, first, and ground levels of the Lorusso Building, providing exit discharge to the exterior of the building, is not equipped with a hard packed walkway in accordance with CMS Survey and Certification Letter 05-38. The ground level stairwell door opens onto an approximate 3 foot by 3 foot concrete pad which leads to a grass lawn. An approximate distance of twenty (20) feet must be traversed before reaching a concrete sidewalk that discharges to a public way.

As a result of the finding the facility is found to be non-compliant with CMS Survey and Certification Letter 05-38, Chapter 7 Section 7.1.7.1 and Chapter 7 Section 7.7.1

These findings were acknowledged by the Hospital's Administrative team during the exit interview.

Based on observations and confirmed by staff, the Hospital failed to ensure that hazardous areas/locations are maintained as required.

Section 19.3.2.1 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.

Section 19.3.2.1.3 states the doors shall be self-closing or automatic-closing.

THE FINDINGS INCLUDE:

During the morning and afternoon hours of 11/14/17 the following items were observed as deficient regarding hazardous areas/locations:

1) The door to the hazardous closet on the Maternity Unit is non-rated. This non-sprinklered closet has a 3-hour rated door frame but is equipped with a non-labeled solid core wood door.

2) The door to the X-ponder closet (1032) on the 1st floor level is non-rated. This non-sprinklered closet has a 3-hour rated door frame but is equipped with a non-labeled solid core wood door.

As a result of the deficient practices listed above, the Hospital failed to comply with section 19.3.2.1 requiring hazardous areas/locations to be properly separated or sprinklered.

These findings were acknowledged by the Hospital's Administrative team during the exit interview.

Based on record review and confirmed by staff, it was revealed that the facility failed to ensure the fire alarm system is maintained as required.

NFPA 101, section 4.5.8 states that whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained, unless the Code exempts such maintenance.

NFPA 101, Section 19.3.4.1 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 (National Fire Alarm Code), Section 14.2.1.2.2 states that system defects and malfunctions shall be corrected.

NFPA 72 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.

THE FINDINGS INCLUDE:

During the survey condcuted on 11/14/17 - 11/16/17, the facility's sprinkler vendor reports dated 9/29/16, 12/19/16, 3/20/17, 6/19/17, and 9/22/17 were reviewed in addition to vendor service requests dated 7//21/17 and 9/28/17. The following items have been identified as not functioning properly.

- The strobe located by OR 10 was not properly functioning as identified on the 7/21/17 vendor service request.
- The smoke detectors in the Lorusso elevator lobby were identified as reporting but not providing an indicator light.
- Three duct smoke detectors were identified as reporting but not providing an indicator light.

As a result, the facility failed to comply with the above NFPA 72, Section 14.2.1.2.2.

This was reviewed with and acknowledged by the facility's Director of Maintenance during record review. These findings were acknowledged by the Hospital's Administrative team during the exit interview.

Based on observations the facility failed to ensure compliance with the following NFPA regulations.

-NFPA 101 Life Safety Code , 2012 edition, Section 9.7.2.1 states where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

-NFPA 20 Standard for the Installation of Stationary Pumps for Fire Protection, 2010 edition, Section 4.16.2 states that fire pump test outlet control valves shall be supervised closed.

THE FINDINGS INCLUDE:

While conducting the facility tour during the afternoon hours of 11/15/17 observations revealed that the closed test outlet control valve of the facility's electric fire pump was equipped with a supervisory device; however the supervisory device was not electrically connected as evidenced by dead-ended wires.

As a result, the fire pump test outlet control valve was not supervised as required by both Section 9.7.2.1 of NFPA 101 and Section 4.16.2 of NFPA 20.

These findings were acknowledged by the Hospital's Administrative team during the exit interview.

Based on observations and records provided, the facility failed to properly maintain the sprinkler system. NFPA 101, Section 19.3.5.7 states where this code permits exceptions for fully sprinklered buildings or smoke compartments, the sprinkler system shall meet all of the following criteria:
(1) It shall be in accordance with Section 9.7.
(2) It shall be installed in accordance with 9.7.1.1(1), unless it is an approved existing system.
(3) It shall be electrically connected to the fire alarm system.
(4) It shall be fully supervised.
(5) In Type I and Type II construction, where the authority having jurisdiction has prohibited sprinklers, approved alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas without causing a building to be classified as non-sprinklered.

NFPA 101 section 9.7.1.1 states each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

NFPA 101 section 9.7.5 states that all automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25 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 4.3.1 states records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.

Section 4.3.2 states records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

Section 4.3.3 states records shall be maintained by the property owner.

NFPA 25, section 5.2.4.1 Gauges 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.

NFPA 25, section 5.2.4.2 Gauges on dry, preaction, and deluge systems shall be inspected weekly to ensure that normal air and water pressures are being maintained.

NFPA 25, section 5.2.4.3 Where air pressure supervision is connected to a constantly attended location, gauges shall be inspected monthly.

NFPA 13, section 7.1.1.2 states pressure gauges shall be installed above and below each alarm check valve or system riser check valve where such devices are present.

THE FINDINGS INCLUDE:

1. The gauges on the wet type sprinkler system were not inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained in accordance with NFPA 25, Section.5.2.4.1.

2. The gauges on the preaction sprinkler system were not inspected weekly to ensure that they are in good condition and that normal water supply pressure is being maintained in accordance with NFPA 25, Section.5.2.4.2.

3. The automatic sprinkler system main, located in the basement of the Draper Building, is equipped with a reduced pressure backflow preventer (check valve) before the system riser. There is no pressure gauge installed before the backflow valve. If the automatic sprinkler system were to lose supply (municipal) pressure the system gauge would still read normal pressure as the check valve would prohibit the system side pressure to drop. This would result in a false indication that the system would perform adequately if called upon to do so. As a result of the finding the facility is found to be non-compliant with Chapter 7 Section 7.1.1.2 of the 2010 edition of NFPA 13 "Standard for the Installation of Sprinkler Systems".

These findings were acknowledged by the Hospital's Administrative team during the exit interview.

Based on observations and records provided, the facility failed to properly maintain the sprinkler system. NFPA 101, Section 19.3.5.7 states where this code permits exceptions for fully sprinklered buildings or smoke compartments, the sprinkler system shall meet all of the following criteria:
(1) It shall be in accordance with Section 9.7.
(2) It shall be installed in accordance with 9.7.1.1(1), unless it is an approved existing system.
(3) It shall be electrically connected to the fire alarm system.
(4) It shall be fully supervised.
(5) In Type I and Type II construction, where the authority having jurisdiction has prohibited sprinklers, approved alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas without causing a building to be classified as non-sprinklered.

NFPA 101 section 9.7.5 states that all automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25 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 4.3.1 states records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.

Section 4.3.2 states records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

Section 4.3.3 states records shall be maintained by the property owner.

NFPA 25, 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 5.2.1.1.2 states any sprinkler that shows signs of any of the following shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5) Loading
(6) Painting unless painted by the sprinkler manufacturer

Section 5.2.1.1.3 states any sprinkler that has been installed in the incorrect orientation shall be replaced.

NFPA 25, 5.2.4.1 Gauges 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.

NFPA 25, 5.2.4.2 Gauges on dry, preaction, and deluge systems shall be inspected weekly to ensure that normal air and water pressures are being maintained.

NFPA 25, 5.2.4.3 Where air pressure supervision is connected to a constantly attended location, gauges shall be inspected monthly.

NFPA 25, 13.7.1 Fire department connections shall be inspected quarterly to verify the following:
(1) The fire department connections are visible and accessible.
(2) Couplings or swivels are not damaged and rotate smoothly.
(3) Plugs or caps are in place and undamaged.
(4) Gaskets are in place and in good condition.
(5) Identification signs are in place.
(6) The check valve is not leaking.
(7) The automatic drain valve is in place and operating properly.
(8) The fire department connection clapper(s) is in place and operating properly.

NFPA 25, 13.7.2 If fire department connection plugs or caps are not in place, the interior of the connection shall be inspected for obstructions, and it shall be verified that the fire department connection clapper is operational over its full range.
NFPA 25, 13.7.3 Components shall be repaired or replaced as necessary in accordance with the manufacturer ' s instructions.
NFPA 25, 13.7.4 Any obstructions that are present shall be removed.

NFPA 25, Section 5.3.4 states that the freezing point of solutions in antifreeze shall be tested annually by measuring the specific gravity with a hydrometer or refractometer and adjusting the solutions if necessary.

NFPA 25, Section 5.3.4.1 states that solutions shall be in accordance with Table 5.3.4.1(a) and Table 5.3.4.1(b).


NFPA 101, Section 9.7.3.1 states in any occupancy where the character of the fuel for fire is such that extinguishment or control of fire is accomplished by a type of automatic extinguishing system in lieu of an automatic sprinkler system, such system shall be installed in
accordance with the appropriate standard, as determined in accordance with Table 9.7.3.1.
Table 9.7.3.1 requires clean agent extinguishing systems to be installed in accordance with NFPA 2001, Standard on Clean Agent Fire Extinguishing Systems.

NFPA 2001, 2012 edition, Section 7.1.1 At least annually, all systems shall be thoroughly inspected and tested for proper operation by personnel qualified in the installation and testing of clean agent extinguishing systems. Discharge tests shall not be required.
7.1.2 The inspection report with recommendations shall be filed with the owner of the system.
7.1.3 At least semiannually, the agent quantity and pressure of refillable containers shall be checked.
7.1.3.1 For halocarbon clean agents, if a container shows a loss in agent quantity of more than 5 percent or a loss in pressure (adjusted for temperature) of more than 10 percent, it shall be refilled or replaced

THE FINDINGS INCLUDE:

During the survey conducted on 11/14/17 - 11/16/17, the facility's vendor sprinkler report dated 9/29/16, 12/19/16, 3/20/17, 6/19/17, and 9/22/17 were reviewed. In addition, the sprinkler systems were observed.. The following items were noted as deficient:

1. During the morning hours of 11/15/17 while touring the Operating Suite area, corroded sprinkler heads were observed in the following locations:
a) The main Central Storage Room within the suite.
b) The Male Locker Room within the suite.
c) The Laundry Chute Room within the suite.

As a result of the above items, the facility failed to comply with NFPA 25, section 4.1.1 requiring sprinkler systems to be properly maintained.

2. The gauges on the wet type sprinkler system were not inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained in accordance with NFPA 25, Section.5.2.4.1.

3. The gauges on the dry type sprinkler system were not inspected weekly to ensure that they are in good condition and that normal water supply pressure is being maintained in accordance with NFPA 25, Section.5.2.4.2.

4. Three out of the six fire department connection caps were missing from the fire pump test header located on the loading dock. The fire department connection caps are required to be replaced in accordance with NFPA 25, 13.7.3.

5. The anti-freeze system that is located on the loading dock was noted on the 9/29/16 and 12/19/16 vendor testing and inspection reports. However, testing results were not documented. In addition, an e-mail from the vendor to facility personnel dated 11/15/17 was produced that stated the Glycol system was tested in June of 2017, yet,the specific gravity was not documented. As a result, it could not be determined if the freezing point of the antifreeze solution was in accordance with NFPA 25, Table 5.3.4.1(a) and Table 5.3.4.1(b).

6. The Novec 1230 clean agent extinguishment system located in basement telephone room was last tested and inspected on 3/21/17. This system is required to have a semi-annual check of the agent quantity and pressure in accordance with NFPA 2001, Section 7.1.3.

As as result, the facility failed to maintain the sprinkler system in accordance with NFPA 25 and NFPA 2001.

These findings were acknowledged by the Hospital's Administrative team during the exit interview.


16934

Based on observations the facility failed to ensure that smoke barrier openings are protected as required by the 2012 edition of NFPA 101 Life Safety Code.

-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 13.4 in. (44 mm) thick, solid-bonded woodcore
doors
(4) Construction that resists fire for a minimum of 20 minutes.

-Chapter 19 Section 19.3.7.6.2 states doors shall be permitted to have fixed fire window
assemblies in accordance with Section 8.5.

-Chapter 8 Section 8.5.4.5 states fire window assemblies shall comply with 8.3.3.

- Chapter 8 Section 8.3.3.1 states openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices,
anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code.

-Chapter 8 Section 8.3.3.1.1 states fire resistance-rated glazing tested in accordance with ASTM E 119, Standard Test Methods for Fire Tests of Building Construction and Materials, or ANSI/UL 263, Standard for Fire Tests of Building Construction and Materials, shall be permitted in
fire door assemblies and fire window assemblies where tested and installed in accordance with their listings.

-Chapter 8 Section 8.3.3.1.2 states new fire resistance-rated glazing shall be marked in accordance with Table 8.3.3.12 and Table 8.3.4.2. Such marking
shall be permanently affixed.

-Chapter 8 Section 8.3.3.2* states fire protection ratings for products required to comply with 8.3.3 shall be as determined and reported by a nationally recognized testing agency in accordance with NFPA 252, Standard Methods of Fire Tests of Door Assemblies; ANSI/UL 10B,
Standard for Fire Tests of Door Assemblies; ANSI/UL 10C, Standard for Positive Pressure Fire Tests of Door Assemblies; NFPA 257, Standard on Fire Test for Window and Glass Block Assemblies; or ANSI/UL 9, Standard for Fire Tests of Window Assemblies.


-Chapter 8 Section 8.3.3.2.2 states all products required to comply with 8.3.3.2 shall bear an approved label.

THE FINDINGS INCLUDE:

While conducting the facility tour during the morning hours of 11/14/17 observations revealed that the door (#3-179) to the third floor charting room is a component of an identified smoke barrier. Observations further revealed that the door is equipped with an approximate wooden framed 32" x 30" non-rated glass vision panel.

As required by Chapter 19 Section 19.3.7.6 the vision panel must either be of fire-rated glazing in accordance with the requirements of Chapter 8 Section 8.3.3.1.1 or a wired glass panel in a steel frame.

As a result of the finding the facility is found to be non-compliant with Chapter 19 Section 19.3.7.6.

The findings were acknowledged by the Hospital's Administrative team during the exit interview.

Based on observations, record review and confirmed by staff, the facility failed to ensure compliance with sections 4.5.8 and 9.2 requiring the maintenance of Heating Ventilation and Air Conditioning (HVAC) Systems.

4.5.8 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any
other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement,
level of protection, or other feature shall thereafter be maintained, unless the Code exempts such maintenance.

19.5.2.1 Heating, ventilating, and air-conditioning shall comply with the provisions of Section 9.2 and shall be installed in
accordance with the manufacturer ' s specifications, unless otherwise modified by 19.5.2.2.

THE FINDINGS INCLUDE:

Observations during the survey condcuted on 11/14-16/17 revealed a temporary portable heater utilized to provide heat to the interstitial space below the elevated 2nd floor (3rd level) medical surgical floor of the Lorusso Building. The non secured temporary portable heater is located on the exterior of the building, next to the Washington Street driveway. This temporary portable heater has been in place for its' second heating season as the permanent heating source is currently not functioning.

The permanent heating system is required to be maintained in accordance with Section 4.5.8.

As a result, the facility failed to comply with section 9.2 requiring the maintenance of Heating Ventilation and Air Conditioning (HVAC) Systems and Section 4.5.8 which requires the maintenance of equipment.

These findings were acknowledged by the Hospital's Administrative team during the exit interview.

Note: Building #04 "Foxborough Medical Center" is classified and surveyed as existing business occupancy and must meet the regulatory requirements of Chapter 39 Existing Business Occupancies of the 2012 edition of NFPA 101 Life Safety Code.

Based on observations the facility failed to ensure that the HVAC system meets the requirements of Chapter 39 Section 39.5.2 and Chapter 9 Section 9.2 of the 2012 edition of NFPA 101 Life Safety Code.

-Chapter 39 Section 39.5.2 states heating, ventilating and air-conditioning equipment shall comply with the provisions of Chapter 9 Section 9.2.

-Chapter 9 Section 9.2.1 states air-conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless such installations are approved existing installations, which shall be permitted to be continued in service.

-NFPA 90A Chapter 4 Section 4.3.11.2.4 states materials used in the construction of a ceiling plenum shall be noncombustible or shall be limited combustible having a maximum smoke developed index of 50, except as permitted in 4.3.11.2.4.1 through 4.3.11.2.4.3, and shall be
suitable for continuous exposure to the temperature and humidity conditions of the environmental air in the plenum.

Findings Include:

While conducting the facility tour during the morning hours of 11/16/17 observations revealed that the space between the facilities suspended ceiling and the floor deck above is being used as a return air plenum for the HVAC system. Observations further revealed that the building components used in the construction of the ceiling plenum include structural wooden members of a non-fire resistive type.

As a result of the finding the facility is found to be non-compliant with Chapter 9 Section 9.2.1 of NFPA 101 and Chapter 4 Section 4.3.11.2.4 of NFPA 90A.

The findings were acknowledged by the Hospital's Administrative team during the exit interview.

Based on observations and confirmed by staff the Hospital failed to ensure that portable space heaters are used in accordance with Section 19.7.8.

Section 19.7.8 states 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.
(2) The heating elements of such devices do not exceed 212 degrees F(100 degrees C).

THE FINDINGS INCLUDE:

While conducting the facility tour during the morning and afternoon hours of 11/14/17 and 11/15/17, portable electric space heaters with a heating element capable of exceeding 212 degrees F (100 degrees C) were observed in the following locations:

1) The Director's office of Unit 35 was observed to contain an electric coil heater. This heater was non-energized during the time of observation.

2) The office identified as G-217 located in the Pain Management Unit was observed to contain an electric coil heater. This heater was energized and in operation during the time of observation.

These findings were acknowledged by the Hospital's Administrative team during the exit interview.

Based on documentation review the facility failed to ensure that its Category 1 medical gas systems are in compliance with the 2012 edition of NFPA 99 Health Care Facilities Code.

-Section 5.1.14.2.1 states health care facilities with installed medical gas, vacuum,WAGD, or medical support gas systems, or combinations thereof, shall develop and document periodic maintenance programs for these systems and their subcomponents as appropriate to the equipment installed.

-Section 5.1.14.2.2 "Maintenance Programs" requires the following.
-5.1.14.2.2.1 Inventories of medical gas, vacuum, WAGD, and medical support gas systems shall include at least all source subsystems, control valves, alarms, manufactured assemblies containing patient gases, and outlets.
-5.1.14.2.2.2 requires that scheduled inspections for equipment and procedures shall be established through the risk assessment of the facility and developed with consideration
of the original equipment manufacturer recommendations and other recommendations as required by the authority having jurisdiction.
-5.1.14.2.2.3 states that the facility shall be permitted to use any inspection procedure(s) or testing methods established through its own risk assessment.
-5.1.14.2.2.4 states that scheduled maintenance for equipment and procedures shall be established through the risk assessment of the facility and developed with consideration
of the original equipment manufacturer recommendations and other recommendations as required by the authority having jurisdiction.

Findings Include:

A review of life safety documentation conducted during the the survey conducted on 11/14-16/17 indicates that the facility did have the piped medical gas systems inspected and tested in accordance with the applicable sections of the 2012 edition of NFPA 99 Health Care Facilities Code. However, only approximately 24 out of the identified 75 compliance discrepancies were identified as having been repaired.

When questioned, the facility personnel stated that the medical gas systems would have to be shut down to complete all of the repairs.

This finding was acknowledged by the Hospital's Administrative team during the exit interview.

Based on documentation review the facility failed to ensure that its Category 1 medical gas systems are in compliance with the 2012 edition of NFPA 99 Health Care Facilities Code.

-Section 5.1.14.2.1 states health care facilities with installed medical gas, vacuum,WAGD, or medical support gas systems, or combinations thereof, shall develop and document periodic maintenance programs for these systems and their subcomponents as appropriate to the equipment installed.

-Section 5.1.14.2.2 "Maintenance Programs" requires the following.
-5.1.14.2.2.1 Inventories of medical gas, vacuum, WAGD, and medical support gas systems shall include at least all source subsystems, control valves, alarms, manufactured assemblies containing patient gases, and outlets.
-5.1.14.2.2.2 requires that scheduled inspections for equipment and procedures shall be established through the risk assessment of the facility and developed with consideration of the original equipment manufacturer recommendations and other recommendations as required by the authority having jurisdiction.
-5.1.14.2.2.3 states that the facility shall be permitted to use any inspection procedure(s) or testing methods established through its own risk assessment.
-5.1.14.2.2.4 states that scheduled maintenance for equipment and procedures shall be established through the risk assessment of the facility and developed with consideration of the original equipment manufacturer recommendations and other recommendations as required by the authority having jurisdiction.

THE FINDINGS INCLUDE:

A review of life safety documentation conducted during the the survey conducted on 11/14-16/17 indicated that the facility did have the piped medical gas systems inspected and tested in accordance with the applicable sections of the 2012 edition of NFPA 99 Health Care Facilities Code. However, only approximately 24 out of the identified 75 compliance discrepancies were identified as having been repaired.

When questioned, the facility personnel stated that the medical gas systems would have to be shut down to complete all of the repairs.

This finding was acknowledged by the Hospital's Administrative team during the exit interview.

Based on observations and confirmed by staff the Hospital failed to ensure that piped oxygen, vacuum and medical air are labeled in compliance with the requirements of the 2012 edition of NFPA 99 "Health Care Facility Code".

-Section 5.1.11.1.2 states that pipe labels shall be located as follows:
(1) At intervals of not more than 6.1 m (20 ft)
(2) At least once in or above every room
(3) On both sides of walls or partitions penetrated by the piping
(4) At least once in every story height traversed by risers

FINDINGS INCLUDE:

During the morning and afternoon hours of 11/14/17 the following items were observed as deficient regarding piped oxygen, vacuum and medical air labeling.

Third floor nursing units #31, #32, and #33, have piped oxygen and vacuum lines which are located above the ceiling tile. The pipes were not labeled as required.

Second floor nursing units #22 and #23, have piped oxygen, vacuum and medical air lines which are located above the ceiling tiles. The pipes were not labeled as required.

As a result of the finding the facility is found to be non-compliant with Chapter 5 Section 5.1.11.2.


These findings were acknowledged by the Hospital's Administrative team during the exit interview.

Based on observations and confirmed by staff, the Hospital failed to ensure that battery-powered lighting units are provided in the operating rooms.

Section 19.3.2.3 states anesthetizing locations shall be in accordance with Section 8.7 and the provisions of
NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing.

NFPA 99 section 6.3.2.2.11.1 states one or more battery-powered lighting units shall be provided within locations where deep sedation and general anesthesia is administered.

Section 6.3.2.2.11.2 states the lighting level of each unit shall be sufficient to terminate procedures intended to be performed within the operating room.

Section 6.3.2.2.11.3 states the sensor for units shall be wired to the branch circuit(s) serving general lighting within the room.

Section 6.3.2.2.11.4 states units shall be capable of providing lighting for 1-1/2 hours.

Section 6.3.2.2.11.5 states units shall be tested monthly for 30 seconds, and annually for 30 minutes.

THE FINDINGS INCLUDE:

During the morning hours of 11/15/17, it was observed that the seven operating rooms are not equipped with battery-powered lighting units.

As a result, the Hospital failed to comply with NFPA 99 section 6.3.2.2.11.1 requiring battery-powered lighting.

These findings were acknowledged by the Hospital's Administrative team during the exit interview.

Based on observations and confirmed by staff, the Hospital failed to ensure that electrical systems are installed in accordance with NFPA 70 and NFPA 99.

Section 19.3.2.3 states anesthetizing locations shall be in accordance with Section 8.7 and the provisions of
NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing.

NFPA 99 section 6.3.2.2.11.1 states one or more battery-powered lighting units shall be provided within locations where deep sedation and general anesthesia is administered.

Section 6.3.2.2.11.2 states the lighting level of each unit shall be sufficient to terminate procedures intended to be performed within the operating room.

Section 6.3.2.2.11.3 states the sensor for units shall be wired to the branch circuit(s) serving general lighting within the room.

Section 6.3.2.2.11.4 states units shall be capable of providing lighting for 1-1/2 hours.

Section 6.3.2.2.11.5 states units shall be tested monthly for 30 seconds, and annually for 30 minutes.

Section 19.5.1.1 states utilities shall comply with the provisions of Section 9.1.

Section 9.1.2 states electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code,
unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70 section 590.3 (D) states temporary wiring shall be removed immediately upon completion of construction or purpose for which the wiring was installed.

THE FINDINGS INCLUDE:

During the morning and afternoon hours of 11/14/17 and 11/15/17, the following items were observed regarding the installation of the Hospital's electrical system:

1) The two operating rooms located on the Maternity floor are not equipped with battery-powered lighting units.

2) The two operating rooms located in the Day Surgery Unit are not equipped with battery-powered lighting units.

3) Temporary lighting was observed above the lay-in-ceiling tiles in the Maternity Unit. These romex wired lighting fixtures were observed specifically above the ceilings of rooms 2601, 2603 and 2605.

As a result, the Hospital failed to comply with NFPA 99 and NFPA 70.

These findings were acknowledged by the Hospital's Administrative team during the exit interview.

Based on observations and confirmed by staff, the facility failed to ensure that the essential electrical system is monitored as required.

Section 19.5.1.1 states utilities shall comply with the provisions of Section 9.1.

Section 9.1.3 states where required for compliance with this Code, emergency generators and standby power systems shall comply with sections 9.1.3.1 and 9.1.3.2.

Section 9.1.3.1 states emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110 section 7.12.2 states when EPSSs are installed in health care facilities, the installation of the EPSS shall also be in compliance with NFPA 99, "Health Care Facilities Code".

NFPA 99 section 6.4.1.1.17 states a remote annunciator that is 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 700.12 of NFPA 70, National Electrical Code). The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows:

(1) Individual visual signals shall indicate the following:
(a) When the emergency or auxiliary power source is operating to supply power to load
(b) When the battery charger is malfunctioning

(2) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
(a) Low lubricating oil pressure
(b) Low water temperature (below that required in 6.4.1.1.11)
(c) Excessive water temperature
(d) Low fuel when the main fuel storage tank contains less than a 4-hour operating supply
(e) Overcrank (failed to start)
(f) Overspeed

Section 6.4.1.1.17.1 states a remote, common audible alarm shall be provided as specified in 6.4.1.1.17.4 that is powered by the storage battery and located outside of the EPS service room at a work site observable by personnel.

THE FINDINGS INCLUDE:

During the morning hours of 11/15/17 while reviewing the emergency electrical system, it was observed the facility is not equipped with remote audible common alarms at a location readily observed by operating personnel at a regular work station for generators #1 and 2.

As a result, the facility failed to comply with NFPA 99 section 6.4.1.1.17.1 requiring an audible alarm to be located at a work site observable by personnel.

This finding was acknowledged by the Hospital's Administrative team during the exit interview.

Based on observations and documentation review the facility failed to ensure that all components of the Essential Electrical System are maintained in accordance with NFPA regulations.

NFPA 99, Section 6.5.4.1.1.2 states that Generator sets shall be inspected and tested in accordance with 6.4.4.1.1.3.

NFPA 99, Section 6.4.4.1.3 Maintenance of Batteries. Batteries for on-site generators shall be maintained in accordance with NFPA 110,
Standard for Emergency and Standby Power Systems.

NFPA 110, Section 5.6.3.6 The generator set shall be fitted with an integral accessory battery charger, driven by the prime mover and automatic voltage regulator, and capable of charging and maintaining the starting battery unit (and control battery, where used) in a fully charged condition during a running condition.

NFPA 110, Section 8.3.7* Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer ' s specifications.

THE FINDINGS INCLUDE:

Documentation of generator maintenance vendor reports dated 8/11/17. 5/17/17, and 4/4/16 were reviewed during survey conducted on 11/14-16/17. Review of the documentation dated 5/17/17 and 8/11/17 revealed that the "Battery charger not properly set voltage too low." for generators # 5 and #6. The 8/11/17 generator #5 report also indicated "May not make 10 second power failure system starting requirement".

As a result of the indication of the voltage being set too low for the battery charger and the statement regarding the questionable ability to meet the starting requirement, all components of the Essential Electrical System were not maintained in accordance with NFPA 99, Section 6.4.4.1.3 and NFPA 110, Section 8.3.7.

These findings were acknowledged by the Hospital's Administrative team during the exit interview.

Based on observations and documentation review the facility failed to ensure that all components of the Essential Electrical System are maintained in accordance with NFPA regulations.

NFPA 99, Section 6.5.4.1.1.2 states that generator sets shall be inspected and tested in accordance with 6.4.4.1.1.3.

NFPA 99, Section 6.4.4.1.3 Maintenance of Batteries. Batteries for on-site generators shall be maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110, Section 5.6.3.6 The generator set shall be fitted with an integral accessory battery charger, driven by the prime mover and automatic voltage regulator, and capable of charging and maintaining the starting battery unit (and control battery, where used) in a fully charged condition during a running condition.

NFPA 110, Section 8.3.7 Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer ' s specifications.

THE FINDINGS INCLUDE:

Documentation of generator maintenance vendor reports dated 8/11/17, 5/17/17, and 4/4/16 were reviewed during survey on 11/14-16/17. Review of the documentation dated 5/17/17 and 8/11/17 revealed that the "Battery charger not maintaining batteries properly" for generators # 1, 2, and 3.

As a result of the indication of the battery charger not properly maintaining the batteries, all components of the Essential Electrical System were not maintained in accordance with NFPA 99, Section 6.4.4.1.3 and NFPA 110, Section 8.3.7.

These findings were acknowledged by the Hospital's Administrative team during the exit interview.

Based on observation, the medical air intake was not installed in accordance with NFPA 99, Section 5.1.3.6.3.12.

Section 5.1.3.6.3.12 Compressor Intake.
(A) The medical air compressors shall draw their air from a source of clean air.
(B) The medical air intake shall be located a minimum of 7.6m (25 ft) from ventilating system exhausts, fuel storage vents,
combustion vents, plumbing vents, vacuum and WAGD discharges, or areas that can collect vehicular exhausts or other
noxious fumes.
(C) The medical air intake shall be located a minimum of 6m (20 ft) above ground level.
(D) The medical air intake shall be located a minimum of 3.0m
(10 ft) from any door, window, or other opening in the building.
(E) If an air source equal to or better than outside air (e.g., air already filtered for use in operating room ventilating systems)
is available, it shall be permitted to be used for the medical air compressors with the following provisions:
(1) This alternate source of supply air shall be available on a continuous 24-hour-per-day, 7-day-per-week basis.
(2) Ventilating systems having fans with motors or drive belts located in the airstream shall not be used as a source of
medical air intake.

THE FINDINGS INCLUDE:

A visual inspection of the medical air intake, located on the roof, was located approximately fourteen feet from the medical vacuum exhaust and approximately eight feet from the chip tank exhaust.

As a result, the medical air intake is not installed in accordance with NFPA 99, Section 5.1.3.6.3.12 that requires the medical air intake to be located a minimum of 7.6m (25 ft) from ventilating system exhausts, fuel storage vents, combustion vents, plumbing vents, vacuum and WAGD discharges, or areas that can collect vehicular exhausts or other noxious fumes.

These findings were acknowledged by the Hospital's Administrative team during the exit interview.