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Based on observation during the survey, it was determined that the corridor walls did not provide continuous smoke resistive separation in accordance with Life Safety Code Section 19.3.6.1. This deficient practice could affect all resident in the south smoke compartment should smoke and heat spread between use areas and the egress corridor due to the absence of a smoke resistive separation. This was evidenced by the following:

Use areas (reception areas and waiting areas) were not separated from the egress corridor and were not protected to meet the exceptions allowed in Section 19.3.6.1, as required. The south smoke compartment main entry reception and waiting areas were open to the egress corridor. The areas and corridor were not fully protected with automatic smoke detection. Automatic sprinkler protection was provided with a combination of standard response and quick response style sprinkler heads.

Life Safety Code Section 19.3.6.1 requires that corridors be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. Exceptions to 19.3.6.1 allow some areas to be open to the egress corridor depending upon size, use and type of protection provided in the rooms and corridor.

Based on observation and staff interview during the survey, it was determined that the facility failed to install and maintain corridor doors in accordance with Life Safety Code Section 19.3.6.3. This deficient practice could affect all patients within the northwest smoke compartment should the egress corridor become untenable, due to smoke and heat transfer, via the non-latching, non-smoke resistive corridor doors separating rooms from the egress corridor. This was evidenced by the following:

A) Corridor doors were not maintained to positively latch into the door frame, as required.
1. The east O/R suite corridor doors were no longer equipped with positive latching hardware. The double door set appeared to have the original positive latching hardware removed in order to accommodate a power door operator.

2. Recover room #16 would not positively latch due to the door binding on the automatic flush bolt hardware installed on the adjacent door leaf.

B) Corridor doors were not maintained to be smoke resistive, as required.
1. Both sets of double doors (surgery suite east and south corridor doors) were observed to have ? inch gaps between the doors when closed.

2. Special Care Room #16 was observed to have damaged retaining hardware that prevented the door from having a smoke resistive seal against the adjacent leaf.

The Maintenance Supervisor acknowledged the door arrangements during a tour of the facility.
Life Safety Code Section 19.3.6.3.2 requires that corridor doors be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction.
Section 19.3.6.3.1, Exception #2 requires that corridor doors installed within sprinkler protected smoke compartments be constructed to resist the passage of smoke.

Based on observation, record review and staff interview during the survey, it was determined that newly constructed smoke compartments were not in accordance with Life Safety Code Section 19.3.7.1 and 18.3.7.1. This deficient practice could affect all occupants in the north smoke compartment should evacuation of the compartment be required during a fire/smoke condition. This was evidenced by the following:

A) The travel distance from any point in the building to reach a smoke compartment door, was not 200 feet or less, as required.

B) The size of a smoke compartment was not limited to 22,500 sq. ft. or less, as required.

A review of original hospital building construction plans and the design/construction plans for the 2008 addition determined that the newly expanded north smoke compartment exceeded 22, 500 square feet in area and that the travel distance, measured from the cardiac rehabilitation therapy room, exceeded 200 feet to an existing smoke compartment. The 2008 building addition design/construction plans (Code Plan-Page 1-2 dated 06/08/07) specified the design to be in accordance with the 2000 edition of NFPA 101 and the 2006 IBC for an Occupancy Group I-2. The addition (9210 sq. ft.) was not separated from the existing building with fire rated construction (per Plan page 1-2). Travel distance to an existing smoke compartment in the original hospital building was verified during the survey to exceed 200 feet. Hospital Administration staff confirmed that the billing for services provided to cardiac rehabilitation patients in the therapy room is via the hospital Centers for Medicare and Medicaid Services Provider Number 061309.

Life Safety Code, Section 18.3.7.1 and 19-3.7.1 require, in part, that the travel distance from any point to reach a door in the required smoke barrier shall not exceed 200 feet and that smoke compartments be limited to a maximum size of 22,500 sq.ft.
Section 18.1.1.1.1(2) requires that building additions used as a health care occupancy meet the requirements of Chapter 18. Section 4.6.6: Additions shall conform to the provisions for new construction.
Note: the existing wall, separating the service corridor area from the 2008 addition, is not constructed with a one hour fire protection rating (per Plan page 1-2 and observation during the survey). The cross-corridor doors separating the existing service corridor area from the 2008 addition are not compliant with Life Safety Code Section 18.3.7.5 through 18.3.7.8.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain sprinkler protected hazardous areas in accordance with Life Safety Code Section 19.3.2.1. This deficient practice could affect patients within the north smoke compartment should there be smoke and heat transfer between the hazardous area and other portions of the building. This was evidenced by the following:

A) One-hour fire rated corridor doors, protecting hazardous areas, were not maintained to self-close and positively latch into the door frame, as required.
1. The Materials Management storage room, one hour rated corridor door, was arranged with an electric strike installed in the door frame. The Maintenance Supervisor reported that the electric strike was on a timing device that resulted in the door being positively latched in the door frame only during the lunch hour and during overnight hours.

2. The northeast storage room (2008 addition) double corridor doors (one-hour fire rated) would not self-close and positively latch into the door frame due to a malfunctioning door coordinator.

B) The main boiler room was not maintained to be a smoke resistive enclosure, as required.
1. A 4 inch sprinkler pipe was observed to have unsealed gaps around the pipe where it penetrated the south wall of the room.

2. The room enclosure walls did not appear to have a smoke resistive seal along the top of the wall. The gypsum board did not appear to be continuous to the concrete roof deck. Any type of fire/smoke seal on the top of wall was not visible.

Life Safety Code Section 19.3.2.1 requires that sprinkler protected hazardous areas be separated from other spaces by smoke-resisting construction. Doors installed to protect hazardous areas must be self-closing or automatic closing. Rated fire doors must positively latch into the door frame in accordance with NFPA 80.

Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. This deficient practice could affect all occupants throughout the facility, if code compliant exit doors are not provided for building egress. This was evidenced by the following:

A) Egress doors equipped with delayed-egress special locking hardware, did not have door signage in compliance with Life Safety Code Section 7.2.1.6.1(d). The lettering on the signs installed was smaller than required.

B) The single marked exit door (into the clinic building) was equipped with delayed egress special locking, however, the door swing was not in the direction of egress, as required. The facility has the option of removing the exit sign above this door as it is not a required means of egress.

C) Door latching hardware was not maintained to release when 15 lbf was applied to the panic bar, as required. One of two door leafs (double door set in service corridor) would not unlatch when pressure was applied to the panic bar. The release mechanism appeared to be binding and would not fully engage to release the latch.

The Maintenance Supervisor acknowledged the door arrangements during a tour of the facility.
Life Safety Code Section 7.2.1.6.1(d): On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows:
PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS
Section 7.2.1.4.5 states that the force required to fully open any door manually in a means of egress shall not exceed 15 lbf to release the latch, 30 lbf to set the door in motion, and 15 lbf to open the door to the minimum required width. These forces shall be applied at the latch stile.

Based on record review and staff interview during the survey, it was determined that the facility failed to maintain emergency lighting systems in accordance with National Fire Protection Association (NFPA) 101- Life Safety Code and the referenced NFPA 110. This deficient practice could affect all patients and staff should emergency lighting and power systems fail to operate as designed. This was evidenced by the following:

A) Automatic transfer switches were not exercised monthly, as required. Test records documented the initiation of monthly load tests utilizing one of the four automatic transfer switches installed. The Maintenance Supervisor confirmed that the transfer switches were rotated each month to start the load test, but only one of the four was actually exercised each month during the planned test. Test records documented two actual utility outages in June and October 2013 which resulted in the exercise of all four automatic transfer switches.
NFPA 110 Section 6-4.5 requires that Level 1 and Level 2 transfer switches be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

B) Records were not available to document monthly generator testing in accordance with NFPA 110 Section 6-4.2, as required. It could not be determined if the diesel powered generator was tested monthly at not less than 30 percent of the nameplate rating. Monthly test records did not document ampere readings to indicate electrical load on each phase.

C) Records were not available to document an annual exercise of the diesel generator with supplemental loads in accordance with NFPA 110 Section 6-4.2.2. The Maintenance Supervisor reported that a supplemental load bank test was scheduled to be conducted in the spring of 2014.

NFPA 110 Section 6-4.2 requires that generator sets in Level 1 and Level 2 service be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
Section 6-4.2.2: Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Based on record review and staff interview during the survey, it was determined that the facility failed to conduct fire drills in accordance with Life Safety Code Sections 19.7.1.2 and 4.7. This deficient practice could affect all patients when staff are not trained in the emergency actions required during the unusual conditions that can occur in an actual emergency. This was evidenced by the following:

A) Fire drills were not conducted quarterly on each shift, as required. The Maintenance Supervisor reported that the hospital operates with two work shifts per 24 hour period. The first shift is from 7 am - 7 pm, and the second shift is from 7 pm - 7 am.

1. Records were not available to document fire drills on the second shift during the prior year.
2. Drill records were not available to document fire drills on the first shift during the 2nd and 4th quarter in 2013.
The Maintenance Supervisor reported that the drills had been conducted, but the documentation could not be located during the survey.

B) Fire drills were not conducted at unexpected times and under varying conditions, as required. A review of fire drill records for the prior 12 month period documented the following drill times during the first shift:

01-14-14 8:08 am
08-23-13 8:23 am
03-29-13 8:17 am

Life Safety Code, Section 19.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held at unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

Based on observation during the survey, it was determined that the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, and NFPA 72, National Fire Alarm Code. This deficient practice could affect patients, staff and visitors should the fire alarm system fail to notify staff in all areas of the building. This was evidenced by the following:

Audible/visual notification appliances were not maintained to alert occupants in all building areas, as required. During a test of the fire alarm system, the notification appliances were not functioning throughout the patient sleeping room smoke compartment.
Life Safety Code Section 9.6.3.8: Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy. Section 9.6.3.7 requires that the general evacuation alarm signal operate throughout the entire building.

Based on observation and staff interview, it was determined that the facility failed to install the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all building occupants should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant installation and maintenance. This was evidenced by the following:

A) Compartmented spaces were not fully protected by quick-response style sprinkler heads, as required. The main entrance foyer and the patient wing corridor (east end with lift storage niche) were protected with a mix of standard response and quick response sprinkler heads.
NFPA Standard 13 Section 5-3.1.5.2 states: "When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed."

B) Sprinkler protection was not provided in all occupiable areas due to features of construction and ceiling obstructions.
1. Main lobby area, west wall (across from the reception desk) was inadequately protected due to obstructions caused by wall configuration. The wall obstruction created a space, approximately 30 inches wide by 20 ft. long that was not adequately protected by the high ceiling horizontal sidewall sprinkler heads. A portion of the obstructed floor area contained upholstered furniture.

2. A standard pendant sprinkler head was obstructed by a ceiling mounted sign box in the CT Room.

3. A standard pendant sprinkler head was obstructed by a 33 inch deep ceiling soffit in the patient wing corridor outside of the family lounge. The pendant sprinkler head was not installed in accordance with the allowed obstructions in NFPA 13 Section 5-6.5.1.2.

The Maintenance Supervisor acknowledged the sprinkler head arrangements during a tour of the facility.

Based on observation, record review and staff interview, it was determined that the facility failed to install and maintain the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all patients should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant installation and maintenance. This was evidenced by the following:

A) The pre-action system (2008) was not maintained in accordance with NFPA 25, as required.

1. The pre-action system waterflow alarm was not tested quarterly, as required. In house testing of system waterflow alarms did not document testing of the pre-action system.
NFPA 25 Section 9-2.7 requires that waterflow alarms be tested quarterly in accordance with manufacturer's instructions.

2. Records were not available to document the required annual trip test of the pre-action valve. The 11-21-13 annual sprinkler system inspection report did not document a trip test of the pre-action valve, reference NFPA 25 Section 9-4.3.2.2. The Maintenance Supervision was not aware of any trip testing of the pre-action valve since the original installation in 2008.

3. Records were not available to document the required quarterly testing of the pre-action system low air pressure alarm, reference NFPA 25 Section 9-4.3.2.10.

4. Records on premises did not document the semi-annual testing of the pre-action system main control valve (butterfly) tamper switch. Fire alarm system test records document testing of two butterfly control valve tamper switches. Three butterfly style control valves are installed on the sprinkler system, including the pre-action system main control valve.

B) Sprinkler system pressure gauges were not replaced or calibrated every 5 years, as required. The sprinkler pressure gauges, installed on the wet sprinkler system, were dated 1993 and 2004. The Maintenance Supervisor was not aware of any calibration testing since the original installation.
NFPA 25 Section 9-2.8.2: 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.

C) The pre-action system air pressure gauge was not listed for fire protection service, as required.
NFPA Standard 13 Section 5-15.3.2 requires that pressure gauges be listed and shall have a maximum limit not less than twice the normal system working pressure at the point where installed.

Based on observation and record review during the survey, it was determined that the facility failed to maintain portable fire extinguishers in accordance with NFPA 10, Standard for Portable Fire Extinguishers. This deficient practice could affect all patients should a portable fire extinguisher not be ready for use by any staff member during an emergency. This was evidenced by the following:

Portable fire extinguishers were not inspected annually, as required. Portable fire extinguisher inspection tags were dated February 2013.

NFPA 10 Section 4-4.1: Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

Based on observation during the survey, it was determined that the facility failed to arrange smoking areas in accordance with National Fire Protection Association (NFPA) Life Safety Code Section 19.7.4. This deficient practice could affect patients and staff should discarded smoking materials become an ignition source due to non-code compliant disposal equipment. This was evidenced by the following:

The north employee smoking area, located outside the north service corridor exit door, was not equipped with ashtrays of safe design or metal containers with self-closing covers, as required.
The smoking area was equipped with a single open combination ashtray/trash container. The lower trash can portion of the fixture was observed to contain a mix of trash and discarded smoking materials.

Life Safety Code Section 19.7.4:
(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

Based on record review and observation, it was determined that the facility failed to install and maintain the kitchen exhaust system and fixed extinguishing system in accordance with National Fire Protection Association (NFPA) Standard 96. This deficient practice could affect all occupants of the north smoke compartment should the fixed fire extinguishing equipment or hood & duct system malfunction due to improper installation or maintenance. This was evidenced by the following:

A) The fixed wet chemical fire extinguishing system manual means of system activation was not located in the path of egress, as required. The manual station to activate the wet chemical system was installed on the back wall of the kitchen, approximately 10 feet from the point where two paths of egress are available from the kitchen.
NFPA 96 Section 7-5.1 requires that a readily accessible means for manual activation be located between 42 in. and 60 in. above the floor, located in a path of exit or egress, and clearly identify the hazard protected. The automatic and manual means of system activation external to the control head or releasing device shall be separate and independent of each other so that failure of one will not impair the operation of the other.

B) Invoices documented the cleaning of the hood and duct system on 02-27-14 and 08-06-13. A certificate documenting any areas of the duct system that were not cleaned, was not available for review.
NFPA 96 Section 8-3.1.2: When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned.

C) The fixed wet chemical fire extinguishing system was not inspected every 6 months, as required. Records on premises documented inspections of the fire extinguishing system on 01-08-14 and 02-08-13.
NFPA 96 Section 8-2: An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

D) The 01-08-14 fixed system inspection report documented that the automatic gas shut off valve was inoperative and that the electrical supply to equipment below the exhaust hood did not shut down upon activation of the extinguishing system. Records were not available to document correction of the deficient items noted on the 01-08-14 inspection report.

Based on observation and staff interview during the course of the survey, it was determined that the facility failed to install and maintain the Type I essential electrical system in accordance with NFPA 99-Health Care Facilities. This deficient practice could affect all occupants of the building should Life Safety Branch of the Essential Electrical System fail to operate as designed due to improper equipment installed on the branch circuit. This was evidenced by the following:

The Life Safety Branch of the essential electrical system was supplying branch circuit functions that were not considered essential to life safety nor specifically allowed on the Life Safety Branch in accordance with Section 3-4.2.2.2 (b). Panelboard "L-S-1" was confirmed by the Maintenance Supervisor to be the only panelboard for the Life Safety Branch.

A) Breaker #10 was labeled " magnet lock control panel " . The Maintenance Supervisor believed this branch circuit was for the magnetic hold open devices on the cross-corridor fire/smoke doors. The door magnets are not an allowed function on the life safety branch as the default life safety position of the doors is in the closed position. Holding the doors in the open position is not considered essential to life safety.

B) Breaker #26 was labeled " Clinic lights & exit-Inj Room refrig " The refrigerator appeared to be added to the branch circuit index card.

NFPA 99 Section 3-4.2.2.2 (b) Life Safety Branch: The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101,? Life Safety Code?
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as
specified in Chapter 4, " Gas and Vacuum Systems "
4. * Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.
No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.

Based on observation during the survey, it was determined that the corridor walls did not provide continuous smoke resistive separation in accordance with Life Safety Code Section 19.3.6.1. This deficient practice could affect all resident in the south smoke compartment should smoke and heat spread between use areas and the egress corridor due to the absence of a smoke resistive separation. This was evidenced by the following:

Use areas (reception areas and waiting areas) were not separated from the egress corridor and were not protected to meet the exceptions allowed in Section 19.3.6.1, as required. The south smoke compartment main entry reception and waiting areas were open to the egress corridor. The areas and corridor were not fully protected with automatic smoke detection. Automatic sprinkler protection was provided with a combination of standard response and quick response style sprinkler heads.

Life Safety Code Section 19.3.6.1 requires that corridors be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. Exceptions to 19.3.6.1 allow some areas to be open to the egress corridor depending upon size, use and type of protection provided in the rooms and corridor.

Based on observation and staff interview during the survey, it was determined that the facility failed to install and maintain corridor doors in accordance with Life Safety Code Section 19.3.6.3. This deficient practice could affect all patients within the northwest smoke compartment should the egress corridor become untenable, due to smoke and heat transfer, via the non-latching, non-smoke resistive corridor doors separating rooms from the egress corridor. This was evidenced by the following:

A) Corridor doors were not maintained to positively latch into the door frame, as required.
1. The east O/R suite corridor doors were no longer equipped with positive latching hardware. The double door set appeared to have the original positive latching hardware removed in order to accommodate a power door operator.

2. Recover room #16 would not positively latch due to the door binding on the automatic flush bolt hardware installed on the adjacent door leaf.

B) Corridor doors were not maintained to be smoke resistive, as required.
1. Both sets of double doors (surgery suite east and south corridor doors) were observed to have ? inch gaps between the doors when closed.

2. Special Care Room #16 was observed to have damaged retaining hardware that prevented the door from having a smoke resistive seal against the adjacent leaf.

The Maintenance Supervisor acknowledged the door arrangements during a tour of the facility.
Life Safety Code Section 19.3.6.3.2 requires that corridor doors be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction.
Section 19.3.6.3.1, Exception #2 requires that corridor doors installed within sprinkler protected smoke compartments be constructed to resist the passage of smoke.

Based on observation, record review and staff interview during the survey, it was determined that newly constructed smoke compartments were not in accordance with Life Safety Code Section 19.3.7.1 and 18.3.7.1. This deficient practice could affect all occupants in the north smoke compartment should evacuation of the compartment be required during a fire/smoke condition. This was evidenced by the following:

A) The travel distance from any point in the building to reach a smoke compartment door, was not 200 feet or less, as required.

B) The size of a smoke compartment was not limited to 22,500 sq. ft. or less, as required.

A review of original hospital building construction plans and the design/construction plans for the 2008 addition determined that the newly expanded north smoke compartment exceeded 22, 500 square feet in area and that the travel distance, measured from the cardiac rehabilitation therapy room, exceeded 200 feet to an existing smoke compartment. The 2008 building addition design/construction plans (Code Plan-Page 1-2 dated 06/08/07) specified the design to be in accordance with the 2000 edition of NFPA 101 and the 2006 IBC for an Occupancy Group I-2. The addition (9210 sq. ft.) was not separated from the existing building with fire rated construction (per Plan page 1-2). Travel distance to an existing smoke compartment in the original hospital building was verified during the survey to exceed 200 feet. Hospital Administration staff confirmed that the billing for services provided to cardiac rehabilitation patients in the therapy room is via the hospital Centers for Medicare and Medicaid Services Provider Number 061309.

Life Safety Code, Section 18.3.7.1 and 19-3.7.1 require, in part, that the travel distance from any point to reach a door in the required smoke barrier shall not exceed 200 feet and that smoke compartments be limited to a maximum size of 22,500 sq.ft.
Section 18.1.1.1.1(2) requires that building additions used as a health care occupancy meet the requirements of Chapter 18. Section 4.6.6: Additions shall conform to the provisions for new construction.
Note: the existing wall, separating the service corridor area from the 2008 addition, is not constructed with a one hour fire protection rating (per Plan page 1-2 and observation during the survey). The cross-corridor doors separating the existing service corridor area from the 2008 addition are not compliant with Life Safety Code Section 18.3.7.5 through 18.3.7.8.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain sprinkler protected hazardous areas in accordance with Life Safety Code Section 19.3.2.1. This deficient practice could affect patients within the north smoke compartment should there be smoke and heat transfer between the hazardous area and other portions of the building. This was evidenced by the following:

A) One-hour fire rated corridor doors, protecting hazardous areas, were not maintained to self-close and positively latch into the door frame, as required.
1. The Materials Management storage room, one hour rated corridor door, was arranged with an electric strike installed in the door frame. The Maintenance Supervisor reported that the electric strike was on a timing device that resulted in the door being positively latched in the door frame only during the lunch hour and during overnight hours.

2. The northeast storage room (2008 addition) double corridor doors (one-hour fire rated) would not self-close and positively latch into the door frame due to a malfunctioning door coordinator.

B) The main boiler room was not maintained to be a smoke resistive enclosure, as required.
1. A 4 inch sprinkler pipe was observed to have unsealed gaps around the pipe where it penetrated the south wall of the room.

2. The room enclosure walls did not appear to have a smoke resistive seal along the top of the wall. The gypsum board did not appear to be continuous to the concrete roof deck. Any type of fire/smoke seal on the top of wall was not visible.

Life Safety Code Section 19.3.2.1 requires that sprinkler protected hazardous areas be separated from other spaces by smoke-resisting construction. Doors installed to protect hazardous areas must be self-closing or automatic closing. Rated fire doors must positively latch into the door frame in accordance with NFPA 80.

Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. This deficient practice could affect all occupants throughout the facility, if code compliant exit doors are not provided for building egress. This was evidenced by the following:

A) Egress doors equipped with delayed-egress special locking hardware, did not have door signage in compliance with Life Safety Code Section 7.2.1.6.1(d). The lettering on the signs installed was smaller than required.

B) The single marked exit door (into the clinic building) was equipped with delayed egress special locking, however, the door swing was not in the direction of egress, as required. The facility has the option of removing the exit sign above this door as it is not a required means of egress.

C) Door latching hardware was not maintained to release when 15 lbf was applied to the panic bar, as required. One of two door leafs (double door set in service corridor) would not unlatch when pressure was applied to the panic bar. The release mechanism appeared to be binding and would not fully engage to release the latch.

The Maintenance Supervisor acknowledged the door arrangements during a tour of the facility.
Life Safety Code Section 7.2.1.6.1(d): On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows:
PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS
Section 7.2.1.4.5 states that the force required to fully open any door manually in a means of egress shall not exceed 15 lbf to release the latch, 30 lbf to set the door in motion, and 15 lbf to open the door to the minimum required width. These forces shall be applied at the latch stile.

Based on record review and staff interview during the survey, it was determined that the facility failed to maintain emergency lighting systems in accordance with National Fire Protection Association (NFPA) 101- Life Safety Code and the referenced NFPA 110. This deficient practice could affect all patients and staff should emergency lighting and power systems fail to operate as designed. This was evidenced by the following:

A) Automatic transfer switches were not exercised monthly, as required. Test records documented the initiation of monthly load tests utilizing one of the four automatic transfer switches installed. The Maintenance Supervisor confirmed that the transfer switches were rotated each month to start the load test, but only one of the four was actually exercised each month during the planned test. Test records documented two actual utility outages in June and October 2013 which resulted in the exercise of all four automatic transfer switches.
NFPA 110 Section 6-4.5 requires that Level 1 and Level 2 transfer switches be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

B) Records were not available to document monthly generator testing in accordance with NFPA 110 Section 6-4.2, as required. It could not be determined if the diesel powered generator was tested monthly at not less than 30 percent of the nameplate rating. Monthly test records did not document ampere readings to indicate electrical load on each phase.

C) Records were not available to document an annual exercise of the diesel generator with supplemental loads in accordance with NFPA 110 Section 6-4.2.2. The Maintenance Supervisor reported that a supplemental load bank test was scheduled to be conducted in the spring of 2014.

NFPA 110 Section 6-4.2 requires that generator sets in Level 1 and Level 2 service be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
Section 6-4.2.2: Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Based on record review and staff interview during the survey, it was determined that the facility failed to conduct fire drills in accordance with Life Safety Code Sections 19.7.1.2 and 4.7. This deficient practice could affect all patients when staff are not trained in the emergency actions required during the unusual conditions that can occur in an actual emergency. This was evidenced by the following:

A) Fire drills were not conducted quarterly on each shift, as required. The Maintenance Supervisor reported that the hospital operates with two work shifts per 24 hour period. The first shift is from 7 am - 7 pm, and the second shift is from 7 pm - 7 am.

1. Records were not available to document fire drills on the second shift during the prior year.
2. Drill records were not available to document fire drills on the first shift during the 2nd and 4th quarter in 2013.
The Maintenance Supervisor reported that the drills had been conducted, but the documentation could not be located during the survey.

B) Fire drills were not conducted at unexpected times and under varying conditions, as required. A review of fire drill records for the prior 12 month period documented the following drill times during the first shift:

01-14-14 8:08 am
08-23-13 8:23 am
03-29-13 8:17 am

Life Safety Code, Section 19.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held at unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

Based on observation during the survey, it was determined that the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, and NFPA 72, National Fire Alarm Code. This deficient practice could affect patients, staff and visitors should the fire alarm system fail to notify staff in all areas of the building. This was evidenced by the following:

Audible/visual notification appliances were not maintained to alert occupants in all building areas, as required. During a test of the fire alarm system, the notification appliances were not functioning throughout the patient sleeping room smoke compartment.
Life Safety Code Section 9.6.3.8: Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy. Section 9.6.3.7 requires that the general evacuation alarm signal operate throughout the entire building.

Based on observation and staff interview, it was determined that the facility failed to install the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all building occupants should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant installation and maintenance. This was evidenced by the following:

A) Compartmented spaces were not fully protected by quick-response style sprinkler heads, as required. The main entrance foyer and the patient wing corridor (east end with lift storage niche) were protected with a mix of standard response and quick response sprinkler heads.
NFPA Standard 13 Section 5-3.1.5.2 states: "When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed."

B) Sprinkler protection was not provided in all occupiable areas due to features of construction and ceiling obstructions.
1. Main lobby area, west wall (across from the reception desk) was inadequately protected due to obstructions caused by wall configuration. The wall obstruction created a space, approximately 30 inches wide by 20 ft. long that was not adequately protected by the high ceiling horizontal sidewall sprinkler heads. A portion of the obstructed floor area contained upholstered furniture.

2. A standard pendant sprinkler head was obstructed by a ceiling mounted sign box in the CT Room.

3. A standard pendant sprinkler head was obstructed by a 33 inch deep ceiling soffit in the patient wing corridor outside of the family lounge. The pendant sprinkler head was not installed in accordance with the allowed obstructions in NFPA 13 Section 5-6.5.1.2.

The Maintenance Supervisor acknowledged the sprinkler head arrangements during a tour of the facility.

Based on observation, record review and staff interview, it was determined that the facility failed to install and maintain the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all patients should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant installation and maintenance. This was evidenced by the following:

A) The pre-action system (2008) was not maintained in accordance with NFPA 25, as required.

1. The pre-action system waterflow alarm was not tested quarterly, as required. In house testing of system waterflow alarms did not document testing of the pre-action system.
NFPA 25 Section 9-2.7 requires that waterflow alarms be tested quarterly in accordance with manufacturer's instructions.

2. Records were not available to document the required annual trip test of the pre-action valve. The 11-21-13 annual sprinkler system inspection report did not document a trip test of the pre-action valve, reference NFPA 25 Section 9-4.3.2.2. The Maintenance Supervision was not aware of any trip testing of the pre-action valve since the original installation in 2008.

3. Records were not available to document the required quarterly testing of the pre-action system low air pressure alarm, reference NFPA 25 Section 9-4.3.2.10.

4. Records on premises did not document the semi-annual testing of the pre-action system main control valve (butterfly) tamper switch. Fire alarm system test records document testing of two butterfly control valve tamper switches. Three butterfly style control valves are installed on the sprinkler system, including the pre-action system main control valve.

B) Sprinkler system pressure gauges were not replaced or calibrated every 5 years, as required. The sprinkler pressure gauges, installed on the wet sprinkler system, were dated 1993 and 2004. The Maintenance Supervisor was not aware of any calibration testing since the original installation.
NFPA 25 Section 9-2.8.2: 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.

C) The pre-action system air pressure gauge was not listed for fire protection service, as required.
NFPA Standard 13 Section 5-15.3.2 requires that pressure gauges be listed and shall have a maximum limit not less than twice the normal system working pressure at the point where installed.

Based on observation and record review during the survey, it was determined that the facility failed to maintain portable fire extinguishers in accordance with NFPA 10, Standard for Portable Fire Extinguishers. This deficient practice could affect all patients should a portable fire extinguisher not be ready for use by any staff member during an emergency. This was evidenced by the following:

Portable fire extinguishers were not inspected annually, as required. Portable fire extinguisher inspection tags were dated February 2013.

NFPA 10 Section 4-4.1: Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

Based on observation during the survey, it was determined that the facility failed to arrange smoking areas in accordance with National Fire Protection Association (NFPA) Life Safety Code Section 19.7.4. This deficient practice could affect patients and staff should discarded smoking materials become an ignition source due to non-code compliant disposal equipment. This was evidenced by the following:

The north employee smoking area, located outside the north service corridor exit door, was not equipped with ashtrays of safe design or metal containers with self-closing covers, as required.
The smoking area was equipped with a single open combination ashtray/trash container. The lower trash can portion of the fixture was observed to contain a mix of trash and discarded smoking materials.

Life Safety Code Section 19.7.4:
(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

Based on record review and observation, it was determined that the facility failed to install and maintain the kitchen exhaust system and fixed extinguishing system in accordance with National Fire Protection Association (NFPA) Standard 96. This deficient practice could affect all occupants of the north smoke compartment should the fixed fire extinguishing equipment or hood & duct system malfunction due to improper installation or maintenance. This was evidenced by the following:

A) The fixed wet chemical fire extinguishing system manual means of system activation was not located in the path of egress, as required. The manual station to activate the wet chemical system was installed on the back wall of the kitchen, approximately 10 feet from the point where two paths of egress are available from the kitchen.
NFPA 96 Section 7-5.1 requires that a readily accessible means for manual activation be located between 42 in. and 60 in. above the floor, located in a path of exit or egress, and clearly identify the hazard protected. The automatic and manual means of system activation external to the control head or releasing device shall be separate and independent of each other so that failure of one will not impair the operation of the other.

B) Invoices documented the cleaning of the hood and duct system on 02-27-14 and 08-06-13. A certificate documenting any areas of the duct system that were not cleaned, was not available for review.
NFPA 96 Section 8-3.1.2: When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned.

C) The fixed wet chemical fire extinguishing system was not inspected every 6 months, as required. Records on premises documented inspections of the fire extinguishing system on 01-08-14 and 02-08-13.
NFPA 96 Section 8-2: An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

D) The 01-08-14 fixed system inspection report documented that the automatic gas shut off valve was inoperative and that the electrical supply to equipment below the exhaust hood did not shut down upon activation of the extinguishing system. Records were not available to document correction of the deficient items noted on the 01-08-14 inspection report.

Based on observation and staff interview during the course of the survey, it was determined that the facility failed to install and maintain the Type I essential electrical system in accordance with NFPA 99-Health Care Facilities. This deficient practice could affect all occupants of the building should Life Safety Branch of the Essential Electrical System fail to operate as designed due to improper equipment installed on the branch circuit. This was evidenced by the following:

The Life Safety Branch of the essential electrical system was supplying branch circuit functions that were not considered essential to life safety nor specifically allowed on the Life Safety Branch in accordance with Section 3-4.2.2.2 (b). Panelboard "L-S-1" was confirmed by the Maintenance Supervisor to be the only panelboard for the Life Safety Branch.

A) Breaker #10 was labeled " magnet lock control panel " . The Maintenance Supervisor believed this branch circuit was for the magnetic hold open devices on the cross-corridor fire/smoke doors. The door magnets are not an allowed function on the life safety branch as the default life safety position of the doors is in the closed position. Holding the doors in the open position is not considered essential to life safety.

B) Breaker #26 was labeled " Clinic lights & exit-Inj Room refrig " The refrigerator appeared to be added to the branch circuit index card.

NFPA 99 Section 3-4.2.2.2 (b) Life Safety Branch: The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101,? Life Safety Code?
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as
specified in Chapter 4, " Gas and Vacuum Systems "
4. * Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.
No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.