HospitalInspections.org

RSA 151, He-P 802.07(a)
"Sixty days prior to initiating construction, the hospital shall provide to the department notice and written plans drawn to scale for construction, renovation or structural alterations for the following:
(1) A new building
(2) Structural alterations to any patient area;
(3) Alterations that require approval from local or state authorities: and
(4) Alterations that might affect compliance with the health and safety, fire or building codes, including but not limited to, fire suppression, detection systems and means of egress."

RSA 153:10-b
"All designs of fire protection and warning devices for health care facilities shall be reviewed by the state fire marshal to determine compliance with the requirements of RSA 153:10-b, and no device shall be installed until it has been approved by the state fire marshal."

Based on observations, interview and record review the facility failed to submit construction plans for review.

Findings include:

Observations during record review on 03/22/17 between 9:00 a.m. and 4:00 p.m. with Staff A (Director of Facilities and Operations), Staff B (Construction Project Coordinator) revealed that the facility failed to submit construction plans for review and approval for renovations, new construction, sprinkler and fire alarm Systems to the Department of Health and Human Services, Health Facilities Administration-State Licensing and the Department of Safety, NH State Fire Marshal's Office.

Interview with Staff A and Staff B confirmed that construction plans had not been submitted.

NFPA 101 (2012 edition) Life Safety Code
4.6.10.2 In buildings under construction, adequate escape facilities shall be maintained at all times for the use of construction workers. Escape facilities shall consist of doors, walkways, stairs, ramps, fire escapes, ladders or other approved means or devices arranged in accordance with the general principles of the code insofar as they can reasonably be applied to buildings under construction. See also NFPA 241 (2009 edition) Standard for Safeguarding Construction, Alteration, and Demolition Operations.

NFPA 241 (2009 edition)
7.1 Fire Safety Program. An overall construction or demolition fire safety program shall be developed. Essential items to be emphasized include the following:
(1) Good housekeeping
(2) On-site security
(3) Installation of new fire protection systems as construction progresses.
(4) Preservation of existing systems during demolition.
(5) Organizations of an on-site fire brigade.
(6) Development of a preferred plan with the local fire department.
(7) Rapid communication.
(8) Considerations of special hazards resulting from previous occupancies.
(9) Protections of existing structures and equipment from exposure fires resulting from construction, alterations, and demolition operations.
7.2 Owners responsibility for Fire Protection
7.2.1 The owner shall designate a person who shall be responsible for the fire prevention program and who shall ensure that it is carried out to completion.
7.2.1.2 The fire prevention program manager shall have knowledge of the applicable fire protection standards, available fire protection systems, and fire inspection procedures.
7.2.1.3 Inspection records shall be available for review by the authority having jurisdiction.
7.2.4 Program Manager Responsibilities
7.2.4.1 The manager shall be responsible for ensuring that proper training in the use of fire protection equipment has been provided.
7..2.4.2 The manager shall be responsible for the presence of adequate numbers and types of fire protection devices and appliances and for their proper maintenance.
7.2.4.5 Impairments to the fire protection systems or fire alarm, detection, or communications systems shall be authorized only by the fire prevention program manager.
7.2.4.6 Temporary protective coverings used on fire protection devices during renovations, such as painting shall be removed promptly when work has been completed in the area.

Based on observations and interview the facility failed to ensure that fire protection devices are returned to operational condition during non-construction hours.

Findings include:

Observations during tour on 03/22/17 between 3:00 p.m. and 4:00 p.m. with Staff A (Director of Facilities and Operations) revealed that construction of the new "Rehabilitation" unit, approximately 4000 sq. ft., had all of the existing smoke detectors completely wrapped with masking tape. The masking tape was not removed during non-construction hours for at least several weeks and effectively disabling the smoke detection devices.

The construction of the new "Emergency Department", approximately 2500 sq. ft. had all but 1 smoke detector removed from the area. The 1 remaining smoke detector was completely wrapped with masking tape. The masking tape was not removed during non-construction hours for an undetermined amount of time and effectively disabling this smoke detection device.

Interview with Staff A confirmed the locations and above findings.

NFPA 110 (2010 edition) Standard for Emergency and Standby Power Systems
7.3 Lighting
7.3.1 The level 1 or level 2 EPS (Emergency Power Supply) equipment locations shall be provided with battery powered emergency lighting.
This requirement shall not apply to units located outdoors in enclosures that do not include walk in access.
7.3.2 The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

Based on observations and interview the facility failed to ensure that battery powered emergency lighting is located at the ATS (Automatic Transfer Switch) location.

Findings include:

Observations during tour on 03/23/17 between 1:30 p.m. and 1:45 p.m. with Staff A (Director of Facilities and Operations), Staff C (Assistant Director of Facilities) and a HHS Licensing Surveyor revealed that the facility has 1 ATS panels located in a main Electrical Room, and one ATS located in a secondary smaller electrical room which are accessed from the back exterior of the hospital. The 2 ATS panel locations failed to be equipped with battery powered emergency task lighting.

Interview with Staff A and Staff C confirmed the findings and locations.

NFPA 96 (2011 edition) Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations
10.5 Manual Activation
10.5.1 A readily accessible means for manual activation shall be located between 42" inches and 48" inches above the floor, be accessible in the event of a fire, be located in a path of egress, and clearly identify the hazard protected.
10.5.1.1 At least one manual actuation device shall be located a minimum of 10' feet and a maximum of 20 feet from the protected kitchen appliance(s) within the path of egress.

Based on observation and interview the facility failed to ensure that the manual pull station, for the Main Kitchen Suppression System, was located in the path of egress and at not less than 10' feet away from the cooking surface.

Findings include:

Observations during tour on 03/23/17 between 2:45 p.m. and 3:00 p.m. with Staff A (Director of Facilities and Operations) and Staff D (Dietary Supervisor) revealed that the Ansul Pull Station (for Fire Suppression) is located approximately 7' feet from the Main Kitchen Stove, behind a food preparation table, and located in a dead end area directly across from the Stove.

Interview with Staff A and Staff D confirmed the location and above findings.

NFPA 101 (2012 edition) Life Safety Code
9.6 Fire Detection, Alarm, and Communication Systems
9.6.1.8 Protection of Fire Alarm System
9.6.1.8.1 In areas that are not continuously occupied, and unless otherwise permitted by 9.6.1.8.1.1 or 9.6.8.1.2, automatic smoke detection shall be installed to provide notification of fire at the following locations:
(1) Each fire alarm control unit
(2) Notification appliance circuit power extenders
(3) Supervising station transmitting equipment
9.6.1.8.1 The Code intends that only one smoke detector is required to be installed at the fire alarm control unit, the notification circuit power extenders, and the supervising station transmitting equipment, even when the area of the room would require more than one smoke detector if installed according to the spacing rules in NFPA 72 National Fire Alarm and Signaling Code.
9.6.1.8.1.1 The provisions of 9.6.1.8.1. (2) and (3) shall not apply to existing alarm systems.

NFPA 72 (2010 edition) National Fire Alarm and Signaling Code
17.7.1.11.1 Where detectors are installed for signaling initiation during construction, they shall be cleaned and verified to be operating in accordance with the listed sensitivity, or they shall be replaced prior to the final commissioning of the system.

Based on observations and interview the facility failed to ensure that a smoke detection device was installed at the FACP (Fire Alarm Control Panel) location and in the temporary hallway separation, next to the Post-op suite.

Findings include:

Observations during tour on 03/23/17 between 12:30 p.m. and 1:30 p.m. with Staff A (Director of Facilities and Operations) and Staff C (Assistant Director of Facilities) revealed the following 2 locations that failed to have any smoke detection devices:

1. The FACP is located in the basement level of the facility, in a storage room next to the Maintenance Department, and fails to have a smoke detection device installed inside this room.
2. The temporary hallway (construction) separation, located outside the laboratory and post-op suite, which is approximately 40' long and 5'-6" wide fails to have a smoke detection device (temporary) installed.

Interview with Staff A and Staff B on the date and time of observation confirmed the findings and locations.

NFPA 13 (2010 edition) Standard for the Installation of Sprinkler Systems
8.1 Basic requirements
8.1.1 The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers shall be installed throughout the premises.
(2) Sprinklers shall be located so as not to exceed the maximum protection area per sprinkler.

8.3.2.5 The following practices shall be observed to provide sprinklers of other than ordinary-temperature classification unless other temperatures are determined or unless high-temperature sprinklers are used throughout, and temperature selection shall be in accordance with Table 8.3.2.5.
(4) Sprinklers under glass or plastic skylights exposed to the direct rays of the sun shall be of the intermediate-temperature classification.
(10) Sprinklers in walk-in type coolers and freezers with automatic defrosting shall be of the intermediate-temperature classification or higher.

8.5.7 Skylights
8.5.7.1 Sprinklers shall be permitted to be omitted from skylights not exceeding 32 sq. ft. in area, regardless of hazard classification, that are separated by at least 10 ft horizontally from any other unprotected skylight or unprotected ceiling pocket.

Based on observations and interview the facility failed to ensure that complete sprinkler coverage is available in 6 areas of the facility and that the spray pattern is not obstructed on 3 sprinkler heads.

Findings include:

Observations during tour on 03/23/2017 between 9:00 a.m. and 2:00 p.m. with Staff A (Director of Facilities and Operations) and Staff C (Assistant Director of Facilities) revealed the following locations that are missing sprinkler coverage or have obstructed sprinkler head spray patterns:

1. The walk-in Freezer and the walk-in Refrigerator (located in the main Kitchen) are not equipped with sprinkler protection.
2. The skylight over the central Nursing Station is approximately 6' feet wide x 16' feet long and vaulted approximately 6 feet, failed to have any sprinkler protection present.
3. The temporary construction barrier hallway, approximately 40' x 5'-6", located outside of the Laboratory, Post-Op, and a clean linen storage room has a temporary ceiling installed and has blocked all existing sprinkler coverage of this area.
4. The temporary construction barrier hallway, on the new construction side, had 3 sprinkler heads (on flexible lines) inverted and hanging upright in the roof trusses failing to provide adequate sprinkler coverage in this area.
5. Two (2) exit signs, over the Fire Door separations, from the Administration wing and the Nursing wing, are blocking adequate sprinkler coverage.
6. The lower level Medical Records identified as Room "B" had a Medical Records shelving unit blocking adequate sprinkler coverage.

Interview with Staff A and Staff C confirmed the above findings and locations.

NFPA 25 (2011 edition) Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems
4.1.1 Responsibility for Inspection, Testing, Maintenance, and Impairment. The property owner or designated representative shall be responsible for properly maintaining a water based fire protection system.
4.1.4.1 The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by this standard.
5.1.1.2 Table Summary of Sprinkler System Inspection, testing and Maintenance
Obstruction, internal inspection of piping (Frequency) Every 5 years reference 14.2
5.2.1.1.1 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.
5.3.3 Waterflow Alarm devices
5.3.3.1 Mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly.
14.2 Internal Inspection of Piping.
14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler towards the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material.
14.2.1.1 Alternative nondestructive examination methods shall be permitted.
14.2.1.4 Non-metallic pipe shall not be required to be inspected internally.

Based on observations, record review and interview the facility failed to ensure that certain inspections,testing, and maintenance was performed.

Findings include:

Observations and record review during tour on 03/22/2017 and 03/23/2017 with Staff A (Director of Facilities and Operations) and Staff C (Assistant Director of Facilities) revealed the following:

1. Documentation of the last internal Obstruction Test was completed in July 2011 and was due in July 2016. The 5 year Obstruction Test had not been completed at the time of this survey.
2. The sprinkler system water motor gong (located on the back, exterior wall of the facility was turned off.
3. At least 4 sprinkler heads were completely covered with lint, dust and or debris around the Nursing Station and the Patient room hallway.

Interview with Staff A and Staff C confirmed the above findings.

NFPA 101 (2012 edition) LIFE SAFETY CODE
19.3.2.4 Medical Gas. Medical gas storage and administration areas 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 (2012 edition) Health Care Facilities Code
5.1.9.3 Area Alarms. Area alarm panels shall be provided to monitor all medical gas, medical surgical vacuum, and piped WAGD (Waste Anesthetic Gas Disposal) systems supplying the following:
Table A 5.9.1.3
(1) Anesthetizing locations where moderate sedation, deep sedation, or general anesthesia is administered.
(2) Critical Care areas.

High line pressure (for each gas piped to the area)
Low line pressure (for each gas piped to the area)
Low medical-surgical vacuum (if piped to the area)
Low WAD vacuum (if piped to the area)

Based on record review and interview the facility failed to ensure that 3 critical care areas have a medical gas alarm.

Findings include:

Record review on 03/22/2017 between 12:00 p.m. and 1:30 p.m. with Staff A (Director of Facilities and Operations) revealed that the last 3 Medical Gas Manifold System vendor reports, listed "compliance discrepancies" dated: October 6, 2014, October 8, 2015, and October 8, 2016 and revealed the following 3 locations that failed to have area alarms.

These departments are as follows:

(1) PACU (Post Acute Care Unit)
This department fails to have an area alarm.
(2) SCU (Special Care Unit)
This department fails to have an area alarm.
(3) ER (Emergency Department)
This department fails to have an area alarm.

Interview with Staff A confirmed the above vendor reports and findings.

NFPA 99 (2012 edition) Health Care Facilities Code
5.1.3.5.6.4 When vented outside, relief valve vent lines shall be labeled in accordance with 5.1.11.1 in any manner that will distinguish them from the medical gas pipeline.
5.1.11.1.1 Piping shall be labeled by stenciling or adhesive markers that identify the patient medical gas, the support gas, or the vacuum system and include the following:
(1) Name of the gas or vacuum system or the chemical symbol.
(2) Gas or vacuum system color code
(3) Where positive pressure gas piping systems operate at pressures other than the standard gauge pressure in table 5.1.11, the operating pressure in addition to the name of the gas.

Based on record review and interview the facility failed to ensure that certain medical gas piping is properly labeled.

Findings include:

Record review during tour on 03/22/17 between 12:00 p.m. and 1:30 p.m. with Staff A (Director of Facilities and Operations) revealed that the last 3 Medical Gas Manifold System vendor reports, listed "compliance Discrepancies" dated: October 6, 2014, October 8, 2015, and October 8, 2016 revealing the following 4 areas of piping that failed to be labeled:

Oxygen Manifold
a. The pressure relief vent line fails to be labeled as to distinguish itself from the medical gas pipeline.
Medical Air Manifold.
a. The pressure relief vent line fails to be labeled as to distinguish itself from the medical gas pipeline.
Vacuum Pump.
a. The vacuum piping needs to be relabeled with code compliant pipe labels.
Nitrous Oxide Manifold.
a. The pressure relief vent line fails to be labeled as to distinguish itself from the medical gas pipeline.

Interview with Staff A confirmed the "Medical Gas Manifold Systems" vendor reports and findings.

NFPA 101 (2012 edition) Life Safety Code
19.3.2.4 Medical Gas. Medical gas storage and administration areas shall be in accordance with section 8.7 and the provisions of NFPA 99 (2012 edition) Health Care Facilities Code, applicable to administration, testing, and maintenance.

NFPA 99 (2012 edition) Health Care Facilities Code
5.1.3.5.6. Relief Valves
5.1.3.5.6.1 All pressure relief valves shall meet the following requirements:
(1) They shall be of brass, bronze, or stainless steel construction.
(2) They shall be designed for the specific gas service.
(3) They shall have a relief pressure setting not higher than the maximum allowable working pressure (MAWP) of the component with the lowest working pressure rating in the portion of the system being protected.
(4) They shall be vented to the outside of the building, except that relief valves for compressed air systems having less than 3000 cu. ft. shall be permitted to be diffused locally by means that will not restrict the flow.
(5) They shall have a vent discharge line that is not smaller than the size of the relief valve outlet.
(7) They shall not discharge into locations creating potential hazards.
(8) They shall have the discharge terminal turned down and screened to prevent the entry of rain, snow, and vermin.

5.1.3.3.2 Design and Construction. Locations for central supply systems and the storage of positive pressure gases shall meet the following requirements:
(1) They shall be constructed with access to move cylinders. equipment, and so forth, in and out of the location on hand trucks.
(4) If indoors, they shall be constructed and use interior finishes of non-combustible or limited combustible materials such that all walls, floors, ceilings and doors are of a minimum 1-hour fire resistance rating.
(5) Electrical devices shall be physically protected, such as by use of a protective barrier around the electrical device such that it will avoid causing physical damage to the cylinders or containers.
(7) They shall be provided with racks, chains, or other fastenings to secure all cylinders from falling, whether connected, unconnected, full, or empty.

5.1.8.2 Locations.
5.1.8.2.1 Pressure/vacuum indicators shall be readable from a standing position.
5.1.8.2.2 Pressure/vacuum indicators shall be provided at the following locations as a minimum:
(1) Adjacent to the alarm-initiating device for source main line pressure and vacuum alarms in the master alarm system.
(2) At or in area alarm panels to indicate the pressure/vacuum at the alarm-activating device for each system that is monitored by the panel
(3) On the station outlet/inlet side of the zone valves
5.1.8.2.3 All pressure sensing devices and main line pressure gauges downstream of the source valves shall be provided with a gas specific demand check fitting to facilitate service, testing or replacement.

9.3.7.5.2.2 One opening shall be located within 1 foot of the floor and one opening shall be located within 1 foot of the ceiling.
9.3.7.5.2 Natural Ventilation
9.3.7.5.2.1. Natural ventilation shall consist if two non-closeable louvered openings, each having an aggregate free opening area of at least 24 sq. in. per 1000 cubic feet of the fluid designed to be stored in the space and in no case less than 72 sq. in.
9.3.7.5.2.5 Mechanical ventilation shall be provided if the natural ventilation requirements can not be met.
9.3.7.5.3.1 Mechanical exhaust to maintain a negative pressure in the space shall be provided continuously, unless an alternative design is approved by the AHJ.

Based on observation, record review, and interview the facility failed to ensure that the "Medical Gas Manifold System" is maintained to be in compliance.

Findings include:

Record review and observations during tour on 03/22/2017 and 03/23/2017 with Staff A (Director of Facilities and Operations) revealed the last 3 Medical Gas Manifold System vendor reports, dated: October 6th 2014, October 8th 2015, and October 8th 2016 have listed several "compliance discrepancies" that had not been addressed at the time of this survey. The deficiencies are as follows:

Oxygen Manifold
a. The final line gauge fails to have a gas-specific demand check installed to facilitate service, testing or replacement.
b. Both of the high/low pressure switches failed to have a gas-specific demand check installed to facilitate service, testing, or replacement.
c. The pressure relief vent line's piping fails to be compliant medical gas piping.
d. The pressure relief vent line's discharge terminal fails to be screened to prevent the entry of vermin.

Vacuum Pump
a. The low pressure switch failed to be located immediately downstream of the source valve.
b. All the turns, offsets, and other changes in direction to the vacuum piping failed to be brazed.
c. There is no vacuum indicator adjacent to the alarm-initiating device the source main line pressure.

Manifold Room
a. There is an electrical switch that failed to be protected or located below 5 feet from the floor.
b. The facility failed to provide natural or mechanical exhaust ventilation in accordance with 9.3.7.5.1 through 9.3.7.8
c. The facility failed to ensure that some gas cylinders are secured.
d. The facility failed to ensure that a protective cover is installed over the exposed light bulb.

Interview with Staff A confirmed the "Medical Gas Manifold System" vendor report findings and locations.

NFPA 110 (2010 edition) Standard for Emergency and Standby Power Systems
8.4.2 Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
(2) Under operating temperature conditions and at not less than 30 percent of the EPS (Emergency Power Supply) nameplate KW rating.

Based on record review and interview the facility failed to ensure that seven monthly Generator Load Tests and one 4 continuous hour test were completed.

Findings include:

Record review on 03/22/17 between 9:00 a.m. and 4:00 p.m. with Staff A (Director of facilities and Operations) revealed that documentation for the Emergency Generator Set failed to show monthly testing requirements for September 2014 through February 2015. All other monthly documentation was available. The documentation of the 4 continuous hour load test (every 36 Months) was dated 11/20/2013 and due by 11/30/2016. There was no current documentation of the 4 continuous hour load test.

Interview with Staff A confirmed the above findings.

Based on observations and interview the facility failed to ensure that power strips in patient areas are only used for patient care related electrical equipment (PCREE).

Findings include:

Observations during tour on 03/23/17 between 1:30 p.m. and 2:00 p.m. with Staff A (Director of Facilities and Operations) and Staff B (Assistant Director of Facilities) revealed 1 non-hospital grade power strip attached (by what appeared to be a zip tie) to a temporary construction separation wall, across from the Nursing Station. There was a hole drilled through the wall for the cord to be plugged in behind the wall.

Interview with Staff A and Staff B confirmed the above findings.