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Based on record review, observation and interview; the facility failed to ensure the building construction type of the original building and the 1952 and 1974 additions was a permitted type as listed in Table 19.1.6.2. Table 19.1.6.2 requires a two story building of Type II (000) construction to be fully sprinklered in accordance with 19.3.5.1. Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers without causing a building to be classified as nonsprinklered. This deficient practice could affect all patients, staff and visitors in the original building and the 1952 and 1974 additions.

Findings include:

Based on review of RTM Consultants, Inc., Fire Safety Evaluation System (FSES) "Executive Summary" documentation dated 12/30/00 with the Director of Plant Operations during record review from 8:20 a.m. to 11:25 a.m. on 10/16/12, the construction type of the original building and the 1952 and 1974 additions was stated as Type II (000) and the minimum permitted classification for this building is Type II (222). Based on observations with the Director of Plant Operations during a tour of the facility from 12:10 p.m. to 2:30 p.m. on 10/16/12, the first floor of the original building and the 1952 and 1974 additions were not sprinklered except for the medical records storage room, radiology and the gift shop. Based on interview at the time of record review and of the observations, the Director of Plant Operations acknowledged the original building and the 1952 and 1974 additions was not sprinklered except for the medical records storage room, radiology and the gift shop.

1. Based on observation and interview, the facility failed to ensure 8 of 16 vertical stairwell openings were enclosed with construction having at least a one hour fire resistance. LSC 19.3.1.1 requires any vertical opening to be enclosed or protected in accordance with LSC 8.2.5. LSC 8.2.5.2 states the vertical opening shall be enclosed as appropriate for the fire resistance rating of the barrier. LSC 8.2.3.2.1 requires a one hour rated door in a one hour vertical opening. This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on observations with the Director of Plant Operations during a tour of the facility from 12:10 p.m. to 2:30 p.m. on 10/16/12, the following stairwell doors had no fire rating label affixed to each stairwell entry door:
a. the Courtyard stairwell in the basement, the stairwell by the storage room in the basement and stairwell by the maintenance room near the boiler room in the basement.
b. the Courtyard stairwell on the first floor, the stairwell by Radiology on the first floor and the stairwell by Medical Records on the first floor.
c. the Obstetrics area stairwell door by Room 218 on the second floor and the stairwell by the entrance to Obstetrics.
Based on interview at the time of the observations, the Director of Plant Operations acknowledged the aforementioned stairwell entry doors are not rated at least one hour fire resistance.

2. Based on record review, observation and interview; the facility failed to ensure 1 of 1 dumbwaiters was provided with fire doors with a fire protection rating of one hour. This deficient practice could affect any staff or visitor in the vicinity of the dumbwaiter by the Pharmacy in the 1974 building addition.

Findings include:

Based on review of RTM Consultants, Inc., Fire Safety Evaluation System (FSES) "Executive Summary" documentation dated 12/30/00 with the Director of Plant Operations during record review from 8:20 a.m. to 11:25 a.m. on 10/16/12, RTM indicated the dumbwaiter in the 1974 building addition "is equipped with standard steel doors that do not bear a label indicating the fire resistance rating." Based on observation with the Director of Plant Operations during a tour of the facility from 12:10 p.m. to 2:30 p.m. on 10/16/12, the dumbwaiter doors by the Pharmacy in the 1974 addition were not provided with a fire resistance rating on the doors. Based on interview at the time of the observation, the Director of Plant Operations acknowledged the dumbwaiter doors were not provided with a fire resistance rating for the doors.

1. Based on observation and interview, the facility failed to ensure 1 of 2 kitchen doors opening into the Cafeteria is provided with a positive latching device to latch the door into the door frame. This deficient practice could affect staff and visitors in the vicinity of the Cafeteria.

Findings include:

Based on observation with the Director of Plant Operations during a tour of the facility from 12:10 p.m. to 2:30 p.m. on 10/16/12, the kitchen door which opens into the Cafeteria by the serving line was not equipped with a positive latching device to latch the door into the frame. Based on interview at the time of observation, the Director of Plant Operations stated the positive latching mechanism had been removed from the door and acknowledged the door was not equipped with a positive latching device to latch the door into the frame.

2. Based on observation and interview, the facility failed to ensure 1 of 25 doors serving hazardous areas such as soiled linen rooms automatically close and latch into the door frame. This deficient practice could affect 10 patients, staff and visitors in the vicinity of the soiled utility Room 276.

Findings include:

Based on observation with the Director of Plant Operations during a tour of the facility from 12:10 p.m. to 2:30 p.m. on 10/16/12, the entry door to soiled linen Room 276 is equipped with a self closing device, but the door did not close fully to latch into the frame leaving a one inch gap between the door and the frame. Based on interview at the time of the observation, the Director of Plant Operations stated the self closing device on the door was in need of adjustment to self close automatically and acknowledged the entry door to soiled linen Room 276 did not automatically close and latch into the door frame.

Based on observation and interview, the facility failed to ensure lighting for 2 of 4 exit means of egress from the split level basement was arranged so the failure of any single lighting fixture (bulb) would not leave the area in darkness. This deficient practice could affect any staff or visitors needing to exit the facility from the basement exit by the kitchen and the basement exit to the Courtyard.

Findings include:

Based on observations with the Director of Plant Operations during a tour of the facility from 12:10 p.m. to 2:30 p.m. on 10/16/12, the exit means of egress from the basement exit by the kitchen and the basement exit to the Courtyard are each equipped with one light fixture with one bulb. Based on interview at the time of the observations, the Director of Plant Operations acknowledged only one light fixture with one bulb was provided at the exit means of egress from the basement exit by the kitchen and the basement exit to the Courtyard.

Based on record review and interview, the facility failed to conduct quarterly fire drills at unexpected times under varying conditions on the second shift for 3 of 4 quarters and on the third shift for 4 of 4 quarters. This deficient practice affects all patients, staff and visitors in the facility.

Findings include:

Based on review of "Fire Drill Report Form" documentation with the Director of Plant Operations during record review from 8:20 a.m. to 11:25 a.m. on 10/16/12, second shift fire drills conducted on 12/09/11, 03/16/12 and 09/14/12 were conducted, respectively, at 4:10 p.m., 4:40 p.m. and 4:37 p.m. Third shift fire drills conducted on 12/16/11, 03/30/12, 06/04/12, and 08/08/12 were conducted, respectively, at 6:10 a.m., 6:14 a.m., 6:38 a.m. and 6:18 a.m. Based on interview at the time of record review, the Director of Plant Operations acknowledged the aforementioned second and third shift fire drills were not conducted at unexpected times under varying conditions.

Based on observation and interview, the facility failed to ensure a sprinkler head was installed in 1 of 2 elevator rooms to provide coverage for all portions of the building. NFPA 13 at 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be of ordinary or intermediate temperature rating. This deficient practice could affect patients, staff and visitors in the vicinity of the Elevator Machine Room near the Diabetes Education Room.

Findings include:

Based on observation with the Director of Plant Operations during a tour of the facility from 12:10 p.m. to 2:30 p.m. on 10/16/12, the Elevator Machine Room near the Diabetes Education Room was not sprinklered. Based on interview at the time of observation, the Director of Plant Operations acknowledged the Elevator Machine Room near the Diabetes Education Room did not have a sprinkler head installed in the room.

1. Based on record review and interview, the facility failed to ensure 1 of 1 sprinkler system components was inspected quarterly for 1 of 4 calendar quarters. LSC 4.6.12.1 requires any device, equipment or system required for compliance with this Code to be maintained in accordance with applicable NFPA requirements. Sprinkler systems shall be properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 1-8 requires records of inspections and tests of the sprinkler system and its components shall be made available to the authority having jurisdiction upon request. This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on review of Tri State Fire Protection "Fire Sprinkler Inspection Report" documentation dated 08/06/12 and Southwestern Sprinkler Services "Report of Inspection" documentation dated 12/16/11 and 03/02/12 with the Director of Plant Operations during record review from 8:20 a.m. to 11:25 a.m. on 10/16/12, documentation of a second quarter (April, May, June) 2012 sprinkler system inspection report was not available for review. Based on interview at the time of record review, the Director of Plant Operations acknowledged documentation of a second quarter 2012 sprinkler system inspection report was not available for review.

2. Based on observation and interview, the facility failed to ensure 1 of 1 sprinkler systems was continuously maintained in reliable operating condition and inspected and tested periodically. NFPA 25, 2-3.2 requires 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. This deficient practice affects all patients, staff and visitors.

Findings include:

Based on observation with the Director of Plant Operations during a tour of the facility from 12:10 p.m. to 2:30 p.m. on 10/16/12, the sprinkler system riser located in the boiler room had one pressure gauge with a date indicating the gauge was manufactured in 2000 with no additional documentation on the pressure gauge indicating it had been recalibrated within the last five years. Based on interview at the time of observation, the Director of Plant Operations acknowledged the pressure gauge was manufactured in 2000.

3. Based on observation and interview, the facility failed to provide a complete supply of spare sprinklers for the automatic sprinkler system in accordance with NFPA 25, 1998 Edition, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Section 2-4.1.4 requires a supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. This deficient practice could affect all patients, staff and visitors if the sprinkler system had to be shut down because a proper sprinkler wasn't available as a replacement.

Findings include:

Based on observation with the Director of Plant Operations during a tour of the facility from 12:10 p.m. to 2:30 p.m. on 10/16/12, one sidewall spare sprinkler was located in the spare sprinkler cabinet in the basement boiler room. Sidewall sprinkler heads were observed installed in the kitchen during the tour. Based on interview at the time of observation, the Director of Plant Operations acknowledged only one sidewall sprinkler was located on the premises in the spare sprinkler cabinet.

Based on observation and interview, the facility failed to maintain 1 of 1 portable K-class fire extinguishers in the kitchen cooking area in accordance with the requirements of NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition. NFPA 10, 2-3.2 requires fire extinguishers provided for the protection of cooking appliances using combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires. NFPA 10, 2-3.2.1 requires a placard shall be conspicuously placed near the extinguisher which states the fire protection system shall be activated prior to using the fire extinguisher. Since the fixed fire extinguishing system will automatically shut off the fuel source to the cooking appliance, the fixed system should be activated before using a portable fire extinguisher. In this instance, the portable fire extinguisher is supplemental protection. This deficient practice could affect staff or visitors in the vicinity of the kitchen.

Findings include:

Based on observation with the Director of Plant Operations during a tour of the facility from 12:10 p.m. to 2:30 p.m. on 10/16/12, a placard was not conspicuously placed near the K-class portable fire extinguisher which states the fire protection system shall be activated prior to using the K-class portable fire extinguisher. Based on interview at the time of observation, the Director of Plant Operations acknowledged a placard was not conspicuously placed near the K-class portable fire extinguisher stating the fire protection system shall be activated prior to using the K-class portable fire extinguisher.

Based on record review and interview, the facility failed to ensure 3 of 117 fire dampers in the facility were inspected and provided necessary maintenance at least every six years in accordance with the Centers for Medicare & Medicaid Services (CMS) Survey and Certification Group Memo S&C-10-04-LSC dated 10/30/09. Pursuant to Centers for Medicare & Medicaid Services (CMS) Survey and Certification Group Memo S&C-10-04-LSC dated 10/30/09, hospitals may operate under the six year damper testing cycle of the 2007 edition of NFPA 80, Standard for Fire Doors and Other Opening Protectives without special application to CMS. This deficient practice affects all patients, staff and visitors.

Findings include:

Based on review of Life Safety Services (LSS) "Fire & Smoke Damper Inspection Summary Report" documentation dated April 7-9, 2009 and LSS "Invoice" documentation dated 04/14/09 with the Director of Plant Operations during record review from 8:20 a.m. to 11:25 a.m. on 10/16/12, documentation of testing performed for 3 of 117 fire dampers within the last six years was not available for review. The LSS documentation dated April 7-9, 2009 stated fire dampers identified as FD-B-014, FD-1-008 and FD-009 were not tested because they were listed as "nonaccessible." The "Invoice" documentation dated 04/14/09 stated there was nowhere to cut an access door to test the three aforementioned fire dampers. Based on interview at the time of record review, the Director of Plant Operations stated LSS determined the aforementioned fire dampers were in place by the use of cameras inserted into the HVAC system and acknowledged fire damper testing of the aforementioned fire dampers within the last six years was not available for review.

1. Based on record review and interview, the facility failed to ensure a monthly load test for 1 of 1 emergency generators was conducted for 1 of 12 months using one of the three following methods: under operating temperature conditions, at not less than 30% of the Emergency Power Supply (EPS) nameplate rating, or loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. Chapter 3-4.4.1.1 of NFPA 99 requires monthly testing of generators serving the emergency electrical system to be in accordance with NFPA 110. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to 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. NFPA 99, 3-5.4.2 requires a written record of inspection, performance, exercising period and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Emergency Powered Generator Log" and "Inspection Log" documentation with the Director of Plant Operations during record review from 8:20 a.m. to 11:25 a.m. on 10/16/12, monthly load test documentation for March 2012 was not available for review. Based on interview at the time of record review, the Director of Plant Operations acknowledged monthly load test documentation for March 2012 was not available for review.

2. Based on record review and interview, the facility failed to ensure emergency power would be transferred to 1 of 1 emergency generators within 10 seconds of building power loss. NFPA 99, 3-4.1.1.8 states generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. NFPA 99, 3-5.4.2 requires a written record of inspection, performance, exercising period and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Emergency Powered Generator Log" and "Inspection Log" documentation with the Director of Plant Operations during record review from 8:20 a.m. to 11:25 a.m. on 10/16/12, monthly load test documentation of emergency power transfer time for the period of October 2011 through September 2012 was not available for review. Based on interview at the time of record review, the Director of Plant Operations acknowledged monthly load test documentation for emergency power transfer time for the period of October 2011 through September 2012 was not available for review.

3. Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was equipped with a remote manual stop. NFPA 99, Health Care Facilities, 3-4.1.1.4 requires generator sets installed as alternate power sources shall meet the requirements of NFPA 110, Standard for Emergency Standby Power Systems. NFPA 110, 3-5.5.6 requires Level I installations shall have a remote manual stop station of a type similar to a break glass station located outside of the room where the prime mover is located. NFPA 110, 7-1 states NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, contains mandatory requirements for emergency generators and shall be considered part of the requirements of this standard. NFPA 37, 8-2.2(c) requires emergency generators of 100 horsepower of more have provisions for shutting down the engine at the engine and from a remote location. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observation with the Director of Plant Operations during a tour of the facility from 12:10 p.m. to 2:30 p.m. on 10/16/12, a remote shut off device was not found for the 565 kW diesel fired emergency generator. Based on interview at the time of observation, the Director of Plant Operations stated the generator was installed prior to 2003 and acknowledged there is no remote emergency shut off device for the emergency generator.

Based on record review and interview, the facility failed to provide a complete written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period in accordance with LSC, Section 9.7.6.1 in order to protect 12 of 12 patients. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, 1998 Edition, the Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 11-5(d) requires the local fire department be notified of sprinkler impairment and 11-5(e) requires the insurance carrier, alarm company, building owner/manager and other authorities having jurisdiction also be notified. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Perry County Memorial Hospital Policies & Procedures: Fire Alarm Failure" documentation with the Director of Plant Operations during record review from 8:20 a.m. to 11:25 a.m. on 10/16/12, the following was noted:
a. the fire watch policy identified fire alarm system impairment but did not include sprinkler system impairment.
b. the fire watch policy did not include a statement on sprinkler system impairment should the system be impaired for four hours or more in twenty four hour period.
c. the fire watch policy did not include notification of the Indiana State Department of Health, which is the authority having jurisdiction, the building owner and the building insurance carrier.
Based on interview at the time of record review, the Director of Plant Operations acknowledged the written fire watch policy did not include the aforementioned statements.

Based on record review and interview, the facility failed to provide a complete written policy containing procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period in accordance with LSC, Section 9.6.1.8 in order to protect 12 of 12 patients. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Perry County Memorial Hospital Policies & Procedures: Fire Alarm Failure" documentation with the Director of Plant Operations during record review from 8:20 a.m. to 11:25 a.m. on 10/16/12, the following was noted:
a. the fire watch policy did not include a statement on fire alarm system impairment should the system be impaired for four hours or more in twenty four hour period.
b. the fire watch policy did not include notification of the Indiana State Department of Health, which is the authority having jurisdiction.
Based on interview at the time of record review, the Director of Plant Operations acknowledged the written fire watch policy did not include the aforementioned statements.

Based on record review, observation and interview; the facility failed to ensure the building construction type of the original building and the 1952 and 1974 additions was a permitted type as listed in Table 19.1.6.2. Table 19.1.6.2 requires a two story building of Type II (000) construction to be fully sprinklered in accordance with 19.3.5.1. Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers without causing a building to be classified as nonsprinklered. This deficient practice could affect all patients, staff and visitors in the original building and the 1952 and 1974 additions.

Findings include:

Based on review of RTM Consultants, Inc., Fire Safety Evaluation System (FSES) "Executive Summary" documentation dated 12/30/00 with the Director of Plant Operations during record review from 8:20 a.m. to 11:25 a.m. on 10/16/12, the construction type of the original building and the 1952 and 1974 additions was stated as Type II (000) and the minimum permitted classification for this building is Type II (222). Based on observations with the Director of Plant Operations during a tour of the facility from 12:10 p.m. to 2:30 p.m. on 10/16/12, the first floor of the original building and the 1952 and 1974 additions were not sprinklered except for the medical records storage room, radiology and the gift shop. Based on interview at the time of record review and of the observations, the Director of Plant Operations acknowledged the original building and the 1952 and 1974 additions was not sprinklered except for the medical records storage room, radiology and the gift shop.

1. Based on observation and interview, the facility failed to ensure 8 of 16 vertical stairwell openings were enclosed with construction having at least a one hour fire resistance. LSC 19.3.1.1 requires any vertical opening to be enclosed or protected in accordance with LSC 8.2.5. LSC 8.2.5.2 states the vertical opening shall be enclosed as appropriate for the fire resistance rating of the barrier. LSC 8.2.3.2.1 requires a one hour rated door in a one hour vertical opening. This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on observations with the Director of Plant Operations during a tour of the facility from 12:10 p.m. to 2:30 p.m. on 10/16/12, the following stairwell doors had no fire rating label affixed to each stairwell entry door:
a. the Courtyard stairwell in the basement, the stairwell by the storage room in the basement and stairwell by the maintenance room near the boiler room in the basement.
b. the Courtyard stairwell on the first floor, the stairwell by Radiology on the first floor and the stairwell by Medical Records on the first floor.
c. the Obstetrics area stairwell door by Room 218 on the second floor and the stairwell by the entrance to Obstetrics.
Based on interview at the time of the observations, the Director of Plant Operations acknowledged the aforementioned stairwell entry doors are not rated at least one hour fire resistance.

2. Based on record review, observation and interview; the facility failed to ensure 1 of 1 dumbwaiters was provided with fire doors with a fire protection rating of one hour. This deficient practice could affect any staff or visitor in the vicinity of the dumbwaiter by the Pharmacy in the 1974 building addition.

Findings include:

Based on review of RTM Consultants, Inc., Fire Safety Evaluation System (FSES) "Executive Summary" documentation dated 12/30/00 with the Director of Plant Operations during record review from 8:20 a.m. to 11:25 a.m. on 10/16/12, RTM indicated the dumbwaiter in the 1974 building addition "is equipped with standard steel doors that do not bear a label indicating the fire resistance rating." Based on observation with the Director of Plant Operations during a tour of the facility from 12:10 p.m. to 2:30 p.m. on 10/16/12, the dumbwaiter doors by the Pharmacy in the 1974 addition were not provided with a fire resistance rating on the doors. Based on interview at the time of the observation, the Director of Plant Operations acknowledged the dumbwaiter doors were not provided with a fire resistance rating for the doors.

1. Based on observation and interview, the facility failed to ensure 1 of 2 kitchen doors opening into the Cafeteria is provided with a positive latching device to latch the door into the door frame. This deficient practice could affect staff and visitors in the vicinity of the Cafeteria.

Findings include:

Based on observation with the Director of Plant Operations during a tour of the facility from 12:10 p.m. to 2:30 p.m. on 10/16/12, the kitchen door which opens into the Cafeteria by the serving line was not equipped with a positive latching device to latch the door into the frame. Based on interview at the time of observation, the Director of Plant Operations stated the positive latching mechanism had been removed from the door and acknowledged the door was not equipped with a positive latching device to latch the door into the frame.

2. Based on observation and interview, the facility failed to ensure 1 of 25 doors serving hazardous areas such as soiled linen rooms automatically close and latch into the door frame. This deficient practice could affect 10 patients, staff and visitors in the vicinity of the soiled utility Room 276.

Findings include:

Based on observation with the Director of Plant Operations during a tour of the facility from 12:10 p.m. to 2:30 p.m. on 10/16/12, the entry door to soiled linen Room 276 is equipped with a self closing device, but the door did not close fully to latch into the frame leaving a one inch gap between the door and the frame. Based on interview at the time of the observation, the Director of Plant Operations stated the self closing device on the door was in need of adjustment to self close automatically and acknowledged the entry door to soiled linen Room 276 did not automatically close and latch into the door frame.

Based on observation and interview, the facility failed to ensure lighting for 2 of 4 exit means of egress from the split level basement was arranged so the failure of any single lighting fixture (bulb) would not leave the area in darkness. This deficient practice could affect any staff or visitors needing to exit the facility from the basement exit by the kitchen and the basement exit to the Courtyard.

Findings include:

Based on observations with the Director of Plant Operations during a tour of the facility from 12:10 p.m. to 2:30 p.m. on 10/16/12, the exit means of egress from the basement exit by the kitchen and the basement exit to the Courtyard are each equipped with one light fixture with one bulb. Based on interview at the time of the observations, the Director of Plant Operations acknowledged only one light fixture with one bulb was provided at the exit means of egress from the basement exit by the kitchen and the basement exit to the Courtyard.

Based on record review and interview, the facility failed to conduct quarterly fire drills at unexpected times under varying conditions on the second shift for 3 of 4 quarters and on the third shift for 4 of 4 quarters. This deficient practice affects all patients, staff and visitors in the facility.

Findings include:

Based on review of "Fire Drill Report Form" documentation with the Director of Plant Operations during record review from 8:20 a.m. to 11:25 a.m. on 10/16/12, second shift fire drills conducted on 12/09/11, 03/16/12 and 09/14/12 were conducted, respectively, at 4:10 p.m., 4:40 p.m. and 4:37 p.m. Third shift fire drills conducted on 12/16/11, 03/30/12, 06/04/12, and 08/08/12 were conducted, respectively, at 6:10 a.m., 6:14 a.m., 6:38 a.m. and 6:18 a.m. Based on interview at the time of record review, the Director of Plant Operations acknowledged the aforementioned second and third shift fire drills were not conducted at unexpected times under varying conditions.

Based on observation and interview, the facility failed to ensure a sprinkler head was installed in 1 of 2 elevator rooms to provide coverage for all portions of the building. NFPA 13 at 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be of ordinary or intermediate temperature rating. This deficient practice could affect patients, staff and visitors in the vicinity of the Elevator Machine Room near the Diabetes Education Room.

Findings include:

Based on observation with the Director of Plant Operations during a tour of the facility from 12:10 p.m. to 2:30 p.m. on 10/16/12, the Elevator Machine Room near the Diabetes Education Room was not sprinklered. Based on interview at the time of observation, the Director of Plant Operations acknowledged the Elevator Machine Room near the Diabetes Education Room did not have a sprinkler head installed in the room.

1. Based on record review and interview, the facility failed to ensure 1 of 1 sprinkler system components was inspected quarterly for 1 of 4 calendar quarters. LSC 4.6.12.1 requires any device, equipment or system required for compliance with this Code to be maintained in accordance with applicable NFPA requirements. Sprinkler systems shall be properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 1-8 requires records of inspections and tests of the sprinkler system and its components shall be made available to the authority having jurisdiction upon request. This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on review of Tri State Fire Protection "Fire Sprinkler Inspection Report" documentation dated 08/06/12 and Southwestern Sprinkler Services "Report of Inspection" documentation dated 12/16/11 and 03/02/12 with the Director of Plant Operations during record review from 8:20 a.m. to 11:25 a.m. on 10/16/12, documentation of a second quarter (April, May, June) 2012 sprinkler system inspection report was not available for review. Based on interview at the time of record review, the Director of Plant Operations acknowledged documentation of a second quarter 2012 sprinkler system inspection report was not available for review.

2. Based on observation and interview, the facility failed to ensure 1 of 1 sprinkler systems was continuously maintained in reliable operating condition and inspected and tested periodically. NFPA 25, 2-3.2 requires 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. This deficient practice affects all patients, staff and visitors.

Findings include:

Based on observation with the Director of Plant Operations during a tour of the facility from 12:10 p.m. to 2:30 p.m. on 10/16/12, the sprinkler system riser located in the boiler room had one pressure gauge with a date indicating the gauge was manufactured in 2000 with no additional documentation on the pressure gauge indicating it had been recalibrated within the last five years. Based on interview at the time of observation, the Director of Plant Operations acknowledged the pressure gauge was manufactured in 2000.

3. Based on observation and interview, the facility failed to provide a complete supply of spare sprinklers for the automatic sprinkler system in accordance with NFPA 25, 1998 Edition, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Section 2-4.1.4 requires a supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. This deficient practice could affect all patients, staff and visitors if the sprinkler system had to be shut down because a proper sprinkler wasn't available as a replacement.

Findings include:

Based on observation with the Director of Plant Operations during a tour of the facility from 12:10 p.m. to 2:30 p.m. on 10/16/12, one sidewall spare sprinkler was located in the spare sprinkler cabinet in the basement boiler room. Sidewall sprinkler heads were observed installed in the kitchen during the tour. Based on interview at the time of observation, the Director of Plant Operations acknowledged only one sidewall sprinkler was located on the premises in the spare sprinkler cabinet.

Based on observation and interview, the facility failed to maintain 1 of 1 portable K-class fire extinguishers in the kitchen cooking area in accordance with the requirements of NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition. NFPA 10, 2-3.2 requires fire extinguishers provided for the protection of cooking appliances using combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires. NFPA 10, 2-3.2.1 requires a placard shall be conspicuously placed near the extinguisher which states the fire protection system shall be activated prior to using the fire extinguisher. Since the fixed fire extinguishing system will automatically shut off the fuel source to the cooking appliance, the fixed system should be activated before using a portable fire extinguisher. In this instance, the portable fire extinguisher is supplemental protection. This deficient practice could affect staff or visitors in the vicinity of the kitchen.

Findings include:

Based on observation with the Director of Plant Operations during a tour of the facility from 12:10 p.m. to 2:30 p.m. on 10/16/12, a placard was not conspicuously placed near the K-class portable fire extinguisher which states the fire protection system shall be activated prior to using the K-class portable fire extinguisher. Based on interview at the time of observation, the Director of Plant Operations acknowledged a placard was not conspicuously placed near the K-class portable fire extinguisher stating the fire protection system shall be activated prior to using the K-class portable fire extinguisher.

Based on record review and interview, the facility failed to ensure 3 of 117 fire dampers in the facility were inspected and provided necessary maintenance at least every six years in accordance with the Centers for Medicare & Medicaid Services (CMS) Survey and Certification Group Memo S&C-10-04-LSC dated 10/30/09. Pursuant to Centers for Medicare & Medicaid Services (CMS) Survey and Certification Group Memo S&C-10-04-LSC dated 10/30/09, hospitals may operate under the six year damper testing cycle of the 2007 edition of NFPA 80, Standard for Fire Doors and Other Opening Protectives without special application to CMS. This deficient practice affects all patients, staff and visitors.

Findings include:

Based on review of Life Safety Services (LSS) "Fire & Smoke Damper Inspection Summary Report" documentation dated April 7-9, 2009 and LSS "Invoice" documentation dated 04/14/09 with the Director of Plant Operations during record review from 8:20 a.m. to 11:25 a.m. on 10/16/12, documentation of testing performed for 3 of 117 fire dampers within the last six years was not available for review. The LSS documentation dated April 7-9, 2009 stated fire dampers identified as FD-B-014, FD-1-008 and FD-009 were not tested because they were listed as "nonaccessible." The "Invoice" documentation dated 04/14/09 stated there was nowhere to cut an access door to test the three aforementioned fire dampers. Based on interview at the time of record review, the Director of Plant Operations stated LSS determined the aforementioned fire dampers were in place by the use of cameras inserted into the HVAC system and acknowledged fire damper testing of the aforementioned fire dampers within the last six years was not available for review.

1. Based on record review and interview, the facility failed to ensure a monthly load test for 1 of 1 emergency generators was conducted for 1 of 12 months using one of the three following methods: under operating temperature conditions, at not less than 30% of the Emergency Power Supply (EPS) nameplate rating, or loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. Chapter 3-4.4.1.1 of NFPA 99 requires monthly testing of generators serving the emergency electrical system to be in accordance with NFPA 110. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to 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. NFPA 99, 3-5.4.2 requires a written record of inspection, performance, exercising period and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Emergency Powered Generator Log" and "Inspection Log" documentation with the Director of Plant Operations during record review from 8:20 a.m. to 11:25 a.m. on 10/16/12, monthly load test documentation for March 2012 was not available for review. Based on interview at the time of record review, the Director of Plant Operations acknowledged monthly load test documentation for March 2012 was not available for review.

2. Based on record review and interview, the facility failed to ensure emergency power would be transferred to 1 of 1 emergency generators within 10 seconds of building power loss. NFPA 99, 3-4.1.1.8 states generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. NFPA 99, 3-5.4.2 requires a written record of inspection, performance, exercising period and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Emergency Powered Generator Log" and "Inspection Log" documentation with the Director of Plant Operations during record review from 8:20 a.m. to 11:25 a.m. on 10/16/12, monthly load test documentation of emergency power transfer time for the period of October 2011 through September 2012 was not available for review. Based on interview at the time of record review, the Director of Plant Operations acknowledged monthly load test documentation for emergency power transfer time for the period of October 2011 through September 2012 was not available for review.

3. Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was equipped with a remote manual stop. NFPA 99, Health Care Facilities, 3-4.1.1.4 requires generator sets installed as alternate power sources shall meet the requirements of NFPA 110, Standard for Emergency Standby Power Systems. NFPA 110, 3-5.5.6 requires Level I installations shall have a remote manual stop station of a type similar to a break glass station located outside of the room where the prime mover is located. NFPA 110, 7-1 states NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, contains mandatory requirements for emergency generators and shall be considered part of the requirements of this standard. NFPA 37, 8-2.2(c) requires emergency generators of 100 horsepower of more have provisions for shutting down the engine at the engine and from a remote location. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observation with the Director of Plant Operations during a tour of the facility from 12:10 p.m. to 2:30 p.m. on 10/16/12, a remote shut off device was not found for the 565 kW diesel fired emergency generator. Based on interview at the time of observation, the Director of Plant Operations stated the generator was installed prior to 2003 and acknowledged there is no remote emergency shut off device for the emergency generator.

Based on record review and interview, the facility failed to provide a complete written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period in accordance with LSC, Section 9.7.6.1 in order to protect 12 of 12 patients. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, 1998 Edition, the Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 11-5(d) requires the local fire department be notified of sprinkler impairment and 11-5(e) requires the insurance carrier, alarm company, building owner/manager and other authorities having jurisdiction also be notified. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Perry County Memorial Hospital Policies & Procedures: Fire Alarm Failure" documentation with the Director of Plant Operations during record review from 8:20 a.m. to 11:25 a.m. on 10/16/12, the following was noted:
a. the fire watch policy identified fire alarm system impairment but did not include sprinkler system impairment.
b. the fire watch policy did not include a statement on sprinkler system impairment should the system be impaired for four hours or more in twenty four hour period.
c. the fire watch policy did not include notification of the Indiana State Department of Health, which is the authority having jurisdiction, the building owner and the building insurance carrier.
Based on interview at the time of record review, the Director of Plant Operations acknowledged the written fire watch policy did not include the aforementioned statements.

Based on record review and interview, the facility failed to provide a complete written policy containing procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period in accordance with LSC, Section 9.6.1.8 in order to protect 12 of 12 patients. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Perry County Memorial Hospital Policies & Procedures: Fire Alarm Failure" documentation with the Director of Plant Operations during record review from 8:20 a.m. to 11:25 a.m. on 10/16/12, the following was noted:
a. the fire watch policy did not include a statement on fire alarm system impairment should the system be impaired for four hours or more in twenty four hour period.
b. the fire watch policy did not include notification of the Indiana State Department of Health, which is the authority having jurisdiction.
Based on interview at the time of record review, the Director of Plant Operations acknowledged the written fire watch policy did not include the aforementioned statements.