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Based on observation and interview, the facility failed to ensure all doors located in a stairway enclosure or smoke barrier wall corridor close automatically or upon activation of the fire alarm system.

Finding;
(ELA campus)

On December 28, 2016, the evaluator conducted an inspection of the Life Safety Code system. The evaluator went downstairs and observed the stairway enclosure door was open. The door had no self-closing device or magnetic door holder. The evaluator examined the door and doorframe and observed the door itself dragged along the floor. The door dragged and it had to be pulled closed in order to meet the regulation in regards to enclosing the stairway enclosure.

The evaluator inspected the smoke barrier doors. The building engineer activated the fire alarm and only 1 of 2 doors automatically closed upon activation of the fire alarm.

The evaluator held an interview with the building engineer who stated he would fix the door immediately.

In case of fire or smoke emergency, the stairway enclosure and the smoke compartments shall resist the passage of smoke or fire with doors that shall remain closed, or close automatically upon activation of the fire alarm system or a self-closing device.

NFPA 101, 2012 Edition,
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier or partition having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1.
19.3.2.1.3 The doors shall be self-closing or automatic-closing.

Based on observation and interview, the facility failed to ensure the basement main boiler room had an enclosure with an 1-hour fire resistance rating or an automatic fire extinguishing systems at all times.

Finding:
(ELA campus)
On 12/28/16, the evaluator conducted an inspection of the Life Safety Code system. The evaluator inspected the basement boiler room located near the basement outpatient surgery room. The evaluator observed the boiler room housed two large boilers and an electric room were located in a very large interior enclosure separated by a horizontal closing fire door. The heavy fire door was designed to be controlled by a counter weight system to open and close.
The evaluator observed the boiler and electric room fire door separation was not in a closed position and no staff were working in the area. The evaluator observed the fire door was being held open with a large heavy bucket. The counter weight rope that controls the fire door was detached and dangling on the door.
The evaluator held an interview with the building engineer and he stated, "oh, it is broken and we have to fix it."
In case of fire or smoke emergency, the main boiler room and the electric room, hazardous areas, shall be safeguarded with an 1-fire resistance at all times. The fire resistance separation shall be maintained and the door shall not be held open indefinitely at any time.

NFPA 101, 2012 Edition
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

Based on observation and interview, the facility failed to ensure the electrical outlets were installed and maintained in a workmanlike manner at all times.

Finding:
(ELA campus)

On 12/28/16, the evaluator conducted an inspection of the Life Safety Code system. The evaluator inspected the boiler room located in the basement next to the electric room. The evaluator observed an electric junction box attached to a conduit held up by a string behind a boiler and below a basement window.

The evaluator observed new electrical conduit and plug installed on the wall over the equipment located in the pharmacy. Any installation of new electrical system shall be approved by the authority having jurisdiction (Office of Statewide Health Planning and Development) and the permit shall be made available all times.

The evaluator held an interview with the building engineer and he stated he would take care of the electric junction box and conduit as soon as possible.

Based on observation and interview, the facility failed to develop and make available the evacuation and relocation plan to the authority having jurisdiction at all time.

This deficient practice had the potential of staff delaying or not responding in accordance with a developed and practiced plan with clear duties and responsibilities in the event of a fire, disaster, and need for emergency egress and relocation. Success for any fire, disaster, emergency egress and relocation plan is based on current and accurate planning, training and practice. Continuous participation of staff on all shifts in fire, disaster, emergency egress and relocation plan review, assists in ensuring the staff on all shifts are familiar with the facility's fire, disaster, emergency egress and relocation plan and are prepared to put it in effect in the event of an emergency. The staff's level of training and familiarity with the facility's plan affects all the clients and occupants of the facility.

Finding:
(ELA campus)

On December 29, 2016, the evaluator conducted an inspection of the facility's Life Safety Code system.

The evaluator requested the Evacuation and Relocation Plan from the staff in charge who stated the plan was not available.

In case of emergency, the Evacuation and Relocation plan shall be immediately available to the staff and to the authority having jurisdiction at all times. The plan shall be part of and demonstrated during the staff fire drill training.

NFPA 101, 2012 Edition
18.7.2.2 Fire Safety Plan. A written health care occupancy fire
safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire

19.7.1.4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.

19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

Based on observation, interview, and record review, the facility failed to ensure the fire drills were conducted by a competent person and clearly followed the approved fire/evacuation policy and plan including clearing the fire exit corridor at all times. The facility is partially sprinkler / Campus #1 with a basement and 3-stories.

Finding:
(ELA campus)

On 12/28/16, The evaluator conducted an inspection of the Life Safety Code system. The evaluator conducted an interview with the building engineer and he was asked how does the staff handle the patient care equipment located in the corridor in case of a fire or evacuation emergency. The building engineer explained the staff would move all the equipment to one side of the corridor.

The evaluator requested a review of the fire drills and observed the document provided no information how the staff evacuated the area or if a fire alarm device was actually activated at the time of the drill.

In case of fire or evacuation emergency, the fire exit corridor shall be clear of all patient care equipment, and the staff shall be trained regarding where the equipment would be stowed. The fire drills shall clearly document the staff practiced stowing all the equipment in non-patient care areas such as the storage rooms and not in patient sleeping rooms.

NFPA 99, 2012

5.1.22.1.1 Piping shall be labeled by stenciling or adhesive that identify the patient medical gas, the support gas, or the vacuum system and include the following:
(1) Name of the gas or vacuum system or the chemical symbol per Table 5.1.11
(2) Gas or vacuum system color code per Table 5.1.11
(3) Where positive pressure gas piping systems operate at pressure other than the standard gauge pressure in Table 5.1.11, the operating pressure in addition to the name of the gas.

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

Based on observation and interview, the facility failed to ensure the medical gas system, cylinders, piping, maniford, and components are all clearly labeled as to type and name of the gas.

Finding:
(ELA campus)

On December 29, 2016, the evaluator conducted an inspection of the facility medical gas manifold and storage room located in the basement. The evaluator observed oxygen, nitrous oxide, and the manifold held in the same room. The medical gas manifold and piped system were not identified. The facility also had nitrous oxide in the same storage area

The evaluator held an interview with the staff in charge and he stated he would contact the medical gas service company and provide identification for the medical gas lines as soon as possible.

All medical gas cylinder piped system shall be clearly identified as to the type and name of the gas lines at all times.

NFPA 99, 2012 Edition
11.3.2.1 Storage locations shall be outdoors in an enclosure or with an enclosed interior space of noncombustible or limited combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
11.3.2.6 Cylinder or container restraints shall comply with 11.6.2.3
11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures (11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
11.6.5.4 cylinders stored in the open shall be protected as follows: (1) Against extremes of weather and from the ground beneath to prevent rusting (3) During summer, screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail.
Based on observation and interview, the facility failed to ensure the medical gas cylinders were held, secured, precautionary sign posted, and maintained in safe condition at all times.
Finding:
(ELA campus)
On 12/28/16, the evaluator conducted a survey of the Life Safety Code system. The evaluator inspected the generator enclosure and observed 16-small oxygen cylinders leaning along the chain link fenced. The cylinders were leaning over to the side and were no longer upright. the evaluator did not see any precautionary sign posted regarding the oxygen cylinders held in the area. The generator was located approximately 10 feet away.
The evaluator interviewed the building engineer and ask him if this area was approved by the authority having jurisdiction. The building engineer did not answer the question.