HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations through the walls. This could result in the spread of fire and smoke in the event of a fire. This affected 1 of 9 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
8.2.3.1.1 Floor-ceiling assemblies and walls used as fire barriers, including supporting construction, shall be of a design
that has been tested to meet the conditions of acceptance of NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. Fire barriers shall be continuous in accordance with 8.2.2.2.

Findings:

During a tour of the facility with the Director of Plant Operations (DPO) from 2/29/16 through 3/3/16, the walls and ceilings were observed.

On 3/1/16, at 10:23 a.m., the North wall to the restroom located in the laboratory, had three penetrations going through the wall. The penetrations measured approximately 4 inches by 4 inches, 3 inches by 3 inches, and 3 inches by 18 inches.

The above findings were acknowledged during the exit conference by the Chief Executive Officer, the Chief Financial Officer, and the Director of Plant Operations.

Based on observation and interview, the facility failed to maintain the corridor doors in accordance with NFPA 101, to latch and resist the passage of smoke. This was evidenced by doors that failed to latch upon self-closure, and by doors that were impeded from closing. This could result in the failure to contain smoke to a room in the event of a fire. This affected 5 of 9 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
7.2.1.8 Self-Closing Devices.
7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2

19.3.6.3 Corridor Doors.
19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4-in. (4.4-cm) thick, solid-bonded core wood or of construction
that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
19.3.6.3.2* Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

Findings:

During a tour of the facility with the interim Director of Plant Operations (DPO), and Engineering staff (ENG1) from 2/29/16 through 3/3/16, the doors were observed.

Surgery Suite:
On 3/1/16, at 11:55 a.m., the door to cysto room failed to fully close. During interview, staff stated that the bottom of the door was dragging on the floor preventing the door from fully closing. The room was used for storing medical equipment.

Unit 2:
1. On 3/2/16, at 10:38 a.m., the corridor door to patient room 205, failed to latch when closed by engineering staff.

Radiology/Imaging Department:
2. On 3/2/16, at 11:04 a.m., the door to the CT room, was held open by a door stop.

3. On 3/2/16, at 11:04 a.m., the door to the CT Scan room was held open by a door stop, when the door was released by engineering staff, the door failed to latch upon self closure.

4. On 3/2/16, at 11:08 a.m., the door to x-ray room one was held open by a door stop, when the door was released by engineering staff the door failed to latch upon self closure.

5. On 3/2/16, at 11:09 a.m., the door to x-ray room three, was held open by a door stop. When the door was released by engineering staff, the door failed to latch upon self closure.




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6. On 3/1/16, at 11:48 a.m., the door that separated the Recovery Room and the Operating Rooms, had an unauthorized device that held the door open. The door had a kickstand door holder installed at the base of the door that was in use when observed.

7. On 3/2/16, at 10:20 a.m., the door to Room 113, failed to positive latch when the door was manually closed.

The above findings were acknowledged during the exit conference on 3/3/16 by the Chief Executive Officer, the Chief Financial Officer, and the Director of Plant Operations.

Based on observation, record review, and interview, the facility failed to maintain their fire doors to operate without interference, and to prevent the passage of smoke or fire. This was evidenced by rolling fire doors that were not inspected and tested annually, by doors that were not clear from obstructions, and by fire doors that failed to positive latch. This could result in the spread of smoke and fire in the event of a fire. This affected 9 of 9 fire/smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.2.2.2.6* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an
automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be
arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
7.2.1.9.2 Doors Required to Be Self-Closing. Where doors are required to be self-closing and (1) are operated by power upon the approach of a person or (2) are provided with power-assisted manual operation, they shall be permitted in the means of egress under the following conditions:
(1) Doors can be opened manually in accordance with 7.2.1.9.1 to allow egress travel in the event of power failure.
(2) New doors remain in the closed position unless actuated or opened manually.
(3) When actuated, new doors remain open for not more than 30 seconds.
(4) Doors held open for any period of time close - and the power-assist mechanism ceases to function - upon operation of approved smoke detectors installed in such a way as to detect smoke on either side of the door opening in accordance with the provisions of NFPA 72, National Fire Alarm Code.
(5) Doors required to be self-latching are either self-latching or become self-latching upon operation of approved smoke detectors per 7.2.1.9.2(4).
(6) New power-assisted swinging doors comply with BHMA/ANSI A156.19, American National Standard for Power Assist and Low Energy Power Operated Doors.
8.2.3.2 Fire Protection-Rated Opening Protectives.
8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) *Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
1-5.1 Listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.
1-6.1 Only labeled fire doors shall be used.
3-1.4 Operation of Doors. The doors shall swing easily and freely on their hinges. The latches shall operate freely.
3-4.3.2 Components. Fire door hardware shall include hinge brackets, hinges, latches, latch keepers, and operating handle mechanisms; hardware for inactive door or pairs of doors includes top and bottom bolts and keepers.
15-1.4 Repairs. Repairs shall be made and defects that could interfere with operation shall be corrected immediately.
15-2.1 Inspections.
15-2.1.1 Hardware shall be examined frequently and any parts found to be inoperative shall be replaced immediately.
15-2.3.1 Door openings and the surrounding areas shall be kept clear of anything that could obstruct or interfere with the free operation of the door.
15-2.4.1 Self-closing devices shall be kept in proper working condition at all times.
15-2.4.3 All horizontal or vertical sliding and rolling fire doors shall be inspected and tested annually to check for proper operation and full closure. Resetting of the release mechanism shall be done in accordance with the manufacturer's instructions. A written record shall be maintained and shall be made available to the authority having jurisdiction.

Findings:

During the facility tour, and during the testing of the fire alarm system with the Director of Plant Operations (DPO) and Engineering staff (ENG1) from 2/29/16 through 3/3/16, the smoke barrier doors were observed.

1. On 3/1/16, at 11:20 a.m., 1 of 2 cross corridor doors near the kitchen, failed to positive latch when a smoke detector or pull alarm was activated. The door was tested twice, and failed to latch.

2. On 3/1/16, at 11:41 a.m., 2 of 2 cross corridor doors near the cafeteria failed to positive latch when a smoke detector or pull alarm was activated. The door was tested twice, and both leafs failed to latch.




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3. On 3/1/16, at 10:11 a.m., the vertical rolling fire doors, located in the corridor by the Admission/Reception Area, failed to maintain clearance along its track path. Computer cables and a credit card machine obstructed the fire door from closing.

4. At 10:12 a.m., the vertical rolling fire doors with connected fusible links, located in the corridor by the Admission/Reception Area, did not have an annual testing/inspection tag. The annual fire alarm testing report, dated 3/20/15, noted that the door was not tested. The DPO was interviewed, and stated that he did not know if the rolling fire door was tested in the past year, and had no record or evidence that it was tested.

5. At 11:58 a.m., a pair of 90-minute swinging fire doors, located between the GI Lab and classrooms, failed to positive latch one of two doors upon activation of the fire alarm system. The cover plate (used for covering the gap between the two doors) was bent and prevented the door from latching.

6. At 11:59 a.m., a pair of 90-minute swinging fire doors, located by Unit 2 Nurses Station, failed to positive latch two of two doors upon activation of the fire alarm system.

7. On 3/2/16, at 10:21 a.m., a 90-minute swinging fire door, located between Unit 1 and the Intensive Care Unit, failed to positive latch.

The above findings were acknowledged during the exit conference on 3/3/16 by the Chief Executive Officer, the Chief Financial Officer, and the Director of Plant Operations.

Based on observation, the facility failed to protect its hazardous areas from corridors in accordance with NFPA 101. This was evidenced by the failure to ensure that the doors in hazardous areas were equipped with self closing devices, and failed to ensure that doors with a self closing devices latch and resist the passage of smoke. This could result in a fire and/or smoke to spread from one area to another area. This affected 2 of 9 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition Section
19.3 Protection
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safe-guarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to the following:
(1) Boiler and fuel fired heater rooms
(2) Central/bulk laundries larger than 100 ft. (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft. (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

Findings:

During a tour of the facility with Engineering staff (ENG1) from 2/29/16 through 3/3/16, the doors to hazardous areas were observed.

1. On 2/29/16, at 2:52 p.m., the soiled utility room inside the pre-op area did not have a self closure on the door. The room was approximately 8 feet by 8 feet and stored a large gray trash bin and three soiled linen carts. Two of the soiled linen carts were full. This was acknowledged by ENG1 during the survey.

2. On 3/2/16, at 9:48 a.m., the dirty utility room corridor door, located between patient room 404 and 405, failed to latch upon self closure.

The above findings were acknowledged during the exit conference on 3/3/16 by the Chief Executive Officer, the Chief Financial Officer, and the Director of Plant Operations.

Based on observation and interview, the facility failed to maintain an emergency exit door in accordance with NFPA 101. This was evidenced by 1 of 2 required emergency exits in a suite that did not have the fire exit hardware on the door. This resulted in the door not opening when tested. This affected the surgery suite.

NFPA 101, Life Safety Code, 2000 Edition
7.2.1.7 Panic Hardware and Fire Exit Hardware.
7.2.1.7.1 Where a door is required to be equipped with panic or fire exit hardware, such hardware shall meet the following criteria:
(1) It shall consist of cross bars or push pads, the actuating portion of which extends across not less than one-half of the width of the door leaf and not less than 34 in. (86 cm), nor not more than 48 in. (122 cm), above the floor.
Exception: Existing installations shall be permitted to be minimum 30 in.
(76 cm) above the floor.
(2) It shall be constructed so that a horizontal force not to exceed 15 lbf (66 N) actuates the cross bar or push pad and latches.
7.2.1.7.2 Only approved panic hardware shall be used on doors that are not fire doors. Only approved fire exit hardware shall be used on fire doors.
7.2.1.7.3 Required panic hardware and fire exit hardware shall not be equipped with any locking device, set screw, or other arrangement that prevents the release of the latch when pressure is applied to the releasing device. Devices that hold the latch in the retracted position shall be prohibited on fire exit hardware unless listed and approved for that purpose.

Findings:

During a tour of the facility with the Director of Plant Operations (DPO) from 2/29/16 through 3/3/16, the emergency exit doors were observed.

Surgery Suite:
1. On 3/1/16, at 12:06 p.m., the emergency exit door leading to the outside of the facility did not have the right hardware. The door was equipped with a thumb lock and when the DPO tried to open the door, the thumb lock stuck and the door could not be opened. During interview, the surgery technician stated that the door has been tested, and opened during fire drills. The surgery technician stated that he could not remember when the last time the door was opened or tested. During interview, the DPO could not confirm when the last time the door was opened. It was not known how long the door thumb lock had been stuck in the locked position. The DPO stated he would call a locksmith immediately. There were no patients in the surgery suite during this observation.

The above finding was acknowledged during the exit conference on 3/3/16 by the Chief Executive Officer, the Chief Financial Officer, and the Director of Plant Operations.

Based on observation and interview, the facility failed to maintain the battery operated emergency lights. This was evidenced by a battery operated light that failed to illuminate when tested, and by no documentation for the monthly testing and annual testing of the battery operated emergency lights. This affected 1 of 9 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
Section 7.9 Emergency Lighting
7.9.2.4* Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition. Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70, National Electrical Code®.
7.9.2.5 The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention.
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Findings:

During a tour of the facility with Engineering staff (ENG1) from 2/29/16 through 3/3/16, the battery operated lights were tested and observed.

On 3/1/16, at 3:35 p.m., the battery operated light inside pre-op room five failed to fully illuminate when the ENG1 pressed the test button.

The above finding were acknowledged during the exit conference on 3/3/16 by the Chief Executive Officer, by the Chief Financial Officer, and the Director of Plant Operations.

Based on document review and interview, the facility failed to conduct fire drills at unexpected times. This was evidenced by 3 of 4 NOC (night) shift fire drills held within the same time frame for each quarter, and by failing to include the transmission of the fire alarm system during fire drills held after 6 a.m., and before 9:00 p.m. This could result in staff not being prepared to respond in the event of a fire or other emergency. This affected 9 of 9 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1 Evacuation and Relocation Plan and Fire Drills.
19.7.1.2* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 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. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.
19.7.2 Procedure in Case of Fire.
19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then execute immediately their duties as outlined in the fire safety plan.

Findings:

During document review and interview with the Director of Plant Operations (DPO), Engineering staff (ENG1), and (ENG2) from 2/29/16 through 3/3/16, the fire drill reports were reviewed.

1. On 3/1/16, at 9:00 a.m., the fire drill reports provided by DPO and ENG1 documented two NOC (night) shift fire drills that were held at 5:00 a.m., and one was held at 5:15 a.m. The fire drill reports also documented that a fire alarm device was activated during all of the fire drills. During interview, ENG 1 was asked who conducted the fire drills, and ENG 1 stated that he conducted the fire drills with the help of ENG2 and security staff. ENG1 was asked what type of device (pull alarm or smoke detector) was activated during the fire drills. ENG1 stated that no fire alarm device was activated during any of the fire drills, and also stated that staff were alerted of the fire drill by an overhead page system.

The above findings were acknowledged during the exit conference on 3/3/16 by the Chief Executive Officer, the Chief Financial Officer, and the Director of Plant Operations.

Based on observation, record review, and interview, the facility failed to ensure that the fire alarm system was maintained. This was evidenced by A/V (Audible and Visual, alarms that notified occupants of a potential fire) devices that failed to function when testing the fire alarm system, by the fire alarm not heard throughout all occupied spaces, by phone lines to the DACT (Digital Alarm Communicator Transmitter, method for alerting fire department responders) that failed to transmit a fault signal within 4-minutes to the panel and to the monitoring station, by sealed lead acid batteries that exceeded their 4-year replacement period,by the failure to transmit a fire alarm signal at least once a month to ensure that their monitoring company was receiving signals, and by a manual pull station that was obstructed from view. This could result in the delay in notifying occupants and responders during a fire alarm system activation. This affected 9 of 9 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.3.4.3.1 Occupant Notification. Occupant notification shall be accomplished automatically in accordance with 9.6.3.
9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
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.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.
19.3.4.4 Emergency Control. Operation of any activating device in the required fire alarm system shall be arranged to accomplish automatically any control functions to be performed by that device. (See 9.6.5.)
9.6.5.4 Installation of emergency control devices shall be in accordance with NFPA 72, National Fire Alarm Code. The performance of emergency control functions shall not impair the effective response of all required alarm notification functions.
9.6.7.5 A system trouble signal shall be annunciated at the control center by means of audible and visible indicators.

NFPA 72, National Fire Alarm Code, 1999 Edition
1-5.4.4 Distinctive Signals. Fire alarms, supervisory signals, and trouble signals shall be distinctively and descriptively annunciated.
1-5.4.6.1 Visible and audible trouble signals and visible indication of their restoration to normal shall be indicated at the following locations:
(1) Control unit (central equipment) for protected premises fire alarm systems
(2) Building fire command center for emergency voice/ alarm communications service
(3) Central station or remote station location for systems installed in compliance with Chapter 5
1-5.4.6.2 Trouble signals and their restoration to normal shall be visibly and audibly indicated at the proprietary supervising station for systems installed in compliance with Chapter 5.
2-8.2.1 Manual fire alarm boxes shall be located throughout
the protected area so that they are unobstructed and accessible.
4-3.2.1 Audible notification appliances intended for operation in the public mode shall have a sound level of not less than 75 dBA at 10 ft (3 m) or more than 120 dBA at the minimum hearing distance from the audible appliance.
5-5.3.2.1.7 DACT Transmission Means.
5-5.3.2.1.7.1 A DACT shall be connected to two separate means of transmission at the protected premises. The DACT shall be capable of selecting the operable means of transmission in the event of failure of the other means. The primary means of transmission shall be a telephone line (number) connected to the public switched network.
Table 7-2.2 Test Methods
16. Supervising Station Fire Alarm Systems - Transmission Equipment
b. Digital Alarm Communicator Transmitter (DACT)
The primary line from the DACT shall be disconnected. Indication of the DACT trouble signal at the premises shall be verified as well as transmission to the supervising station within 4 minutes of detection of the fault.
The secondary means of transmission from the DACT shall be disconnected. Indication of the DACT trouble signal at the premises shall be verified as well as transmission to the supervising station within 4 minutes of detection of the fault.
Table 7-3.2 Testing Frequencies:
6. Batteries - Fire Alarm Systems (d)(1) Sealed lead acid batteries are to be replaced every 4 years.
23. Supervising Station Fire Alarm System - Receivers (a) DACR are to be tested monthly.

Findings:

During fire alarm testing with the Director of Plant Operations (DPO) and the fire alarm vendor from 2/29/16 through 3/3/16, the fire alarm system was tested and observed.

1. On 2/29/16, at 3:02 p.m., the bell inside the kitchen and the A/V device (combined strobe and chime) located in the corridor by the kitchen, failed to sound the alarm when the Kitchen Suppression System Installer (Vendor) activated the fire alarm system by triggering it at the suppression system. The A/V device was tagged with a green sticker.

2. At 3:05 p.m., the A/V device (combined strobe and chime) located by the Pharmacy was not functioning when the Vendor activated the fire alarm system. The A/V device was tagged with a green sticker.

3. At 3:35 p.m., the annual fire alarm system reports, dated 3/20/15 and 4/9/14, were reviewed and listed several A/V devices that had failed. The report dated 3/20/15 included the A/V devices observed in the corridor by the kitchen and by the Pharmacy and noted that the devices that had failed, were tagged with green stickers.

4. On 3/1/16, at 12:17 p.m., the primary phone line to the DACT failed to transmit a fault signal within 4 minutes after the line was unplugged from the phone jack and left disconnected for more than 5 minutes. During the review of the monitoring station activity report, the fault signal was not listed as being received.

5. At 12:22 p.m., the secondary phone line to the DACT failed to transmit a fault signal within 4 minutes after the line was unplugged from the phone jack and left disconnected for 4 minutes and 7 seconds. During the review of the monitoring station activity report, the fault signal was not listed as being received.

6. On 3/1/16, at 12:04 p.m., there was no audible or visual device in the surgery suite. The chime outside of the surgery suite could faintly be heard in the recovery area, but could not be heard in any of the operating rooms. During interview, the surgical technician stated he could hear the overhead page when there was a fire drill. The DPO confirmed there was not an audible or visual device in the surgery suite.

7. On 3/3/16, at 9:25 a.m., the manual fire alarm pull station located by the Nurse Station in Unit 3, was blocked from view by a door. When a Nurse Staff was interviewed in the area and asked to locate the closest fire alarm pull station, the staff walked passed the pull station behind the door and located a pull station in Unit 2.

The above findings were acknowledged during the exit conference on 3/3/16 by the Chief Executive Officer, the Chief Financial Officer, and the Director of Plant Operations.

Based on document review and interview, the facility failed to test the fire alarm system on a monthly basis with the monitoring station. This was evidenced by the failure to provide documentation for the monthly testing of the fire alarm system in the past 12 months. This could result in fire alarm transmission failure. This affected 9 of 9 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, ,1999 Edition
Table 7-3.2 Testing Frequencies, Item 23 - requires testing with the receiving station on a monthly basis.

Findings:

During document review and interview with Engineering staff (ENG1) from 2/29/16 through 3/3/16, the fire alarm system maintenance reports were observed, and staff were interviewed.

1. On 3/1/16, at 10:08 a.m., the maintenance reports provided by engineering staff for the smoke detectors, manual pull stations, chimes/strobes documented quarterly testing for the devices. The facility smoke detectors written Inspection testing Maintenance policy as follows: "IN ACCORDANCE WITH NFPA 72E 8-2.4.1 TO ASSURE THAT EACH SMOKE DETECTOR IS OPERATIVE AND PRODUCES THE INTENDED RESPONSE, IT SHALL BE CAUSED TO INITIATE AN ALARM AT ITS INSTALL LOCATION WITH SMOKE OR OTHER AEROSOL ACCEPTABLE TO THE MANUFACTURER, THAT DEMONSTRATES THAT SMOKE CAN ENTER THE CHAMBER AND INITIATE AN ALARM."
"IN ACCORDANCE WITH JCAHO GUIDELINES A DESIGNATED PORTION OF SMOKE DETECTORS SHALL BE TESTED QUARTERLY THEREFORE, ALL SMOKE DETECTORS SHALL BE TESTED ANNUALLY TO COMPLY WITH NFPA 72E 8-2.4.1." This policy was reviewed & revised on 7/22/15.

The facility Manual Pull Stations policy written as follows: "IN ACCORDANCE WITH JCAHO GUIDELINES, A DESIGNATED PORTION OF THE PULL STATION SHALL BE TESTED QUARTERLY, THEREFORE ALL MANUAL PULL STATIONS SHALL BE TESTED SEMI ANNUALLY TO COMPLY WITH NFPA 72.H.4.1." This policy was reviewed & revised on 7/10/15.
The facility Chimes policy written as follows: "IN ACCORDANCE WITH THE GUIDELINE. A DESIGNATED PORTION OF CHIMES SHALL BE TESTED QUARTERLY THEREFORE ALL CHIME SHALL BE TESTED SEMI ANNUALLY TO COMPLY WITH NFPA 72H.4.1." This policy was reviewed & revised on 9/9/15.

2. On 3/1/16, at 2:22 p.m., during an interview, ENG1 was asked for the last four quarterly activity reports from the monitoring station. The activity reports would indicate how many fire alarm devices were tested during a specific quarter. ENG1 stated he did not activate/test any devices and stated he only did a visual inspection.

The above findings were acknowledged during the exit conference on 3/3/16 by the Chief Executive Officer, the Chief Financial Officer, and the Director of Plant Operations.










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Based on document review and interview, the facility failed to maintain its smoke detection devices through out the facility. This was evidenced by no written documentation for smoke detector sensitivity testing. This could result in the smoke detectors not functioning as designed, and delay notification staff in the event of a fire. This affected 9 of 9 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.3* The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and
NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
9.6.1.5 All systems and components shall be approved for the purpose for which they are installed.
9.6.1.6 Fire alarm system installation wiring or other transmission paths shall be monitored for integrity in accordance with 9.6.1.4.
9.6.1.7* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70,
National Electrical Code, and NFPA 72, National Fire Alarm Code.

NFPA 72, National Fire Alarm Code, 1999 Edition
7-3.2.1* Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the
detector causes a signal at the control unit where its sensitivity
is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the
authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted
to be either adjusted within the listed and marked sensitivity range and
cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors
referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During document review and interview with the Director of Plant Operations (DPO) and Engineering staff (ENG1) from 2/19/16 through 3/3/16, the smoke detector sensitivity reports were requested.

1. On 3/1/16, at 4:33 p.m., the facility failed to provide written documentation for smoke detector sensitivity. The reports provided for fire alarm testing & inspection dated 3/20/15 and 4/9/14 did not include sensitivity testing, and the reports also had discrepancies. The report dated 4/9/14, had the total number of smoke detector were 46 and the total of smoke detectors tested on 3/20/15 were 36. The total number of smoke detectors on the facility visual inspection form was 43. During interview, the DPO stated he did not have any additional records for review and ENG1 stated that he did not know the exact number of smoke detectors in the facility.

The above findings were acknowledged during the exit conference on 3/3/16 by the Chief Executive Officer, the Chief Financial Officer, and the Director of Plant Operations.

Based on observation, document review and interview, the facility failed to maintain the integrity of the sprinkler system. This was evidenced by 3 of 3 Post Indicator Valve (PIV) failures to initiate an audible trouble signal at the remote annunciator panel when the valves were closed, by 1 of 3 Post Indicator Valves (PIV) that failed to send a distinctive signal to the remote annunciator panel, to the Fire Alarm Control Panel (FACP), and to the monitoring station, and by incomplete documentation for the quarterly testing of the 3 Post Indicator Valves. This could result in the failure to respond to the tampering of the sprinkler system. This affected 9 of 9 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
9.7.2 Supervision.
9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.
9.7.2.2 Alarm Signal Transmission. Where supervision of automatic sprinkler systems is provided in accordance with another provision of this Code, waterflow alarms shall be transmitted to an approved, proprietary alarm receiving facility, a remote station, a central station, or the fire department. Such connection shall be in accordance with 9.6.1.4.

NFPA 72, National Fire Alarm Code, 1999 Edition
1-5.4.4 Distinctive Signals. Fire Alarms, Supervisory signals, and trouble signals shall be distinctively and descriptively annunciated .
1-5.4.6.1 Visible and audible trouble signals and visible indication of their restoration to normal shall be indicated at the following locations:
(1) Control unit (central equipment) for protected premises fire alarm systems
(2) Building fire command center for emergency voice/alarm communications service
(3) Central station or remote station location for systems installed in compliance with Chapter 5
3-8.3.3.1.3 Signals shall distinctively indicate the particular function (e.g., valve position, temperature, or pressure) of the system that is off-normal and also indicate its restoration to normal.
3-8.3.4.2 The integrity of each fire suppression system actuating device and its circuit shall be supervised in accordance with 1-5.8.1 and with other applicable NFPA standards.
Table 7-2.2
10. Remote Annunciators The correct operation and identification of annunciators shall be verified. If provided, the correct operation of annunciator under a fault condition shall be verified.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
9-3.4.3 Valve supervisory switches shall be tested semiannually. A distinctive signal shall indicate movement from the valve's normal position during either the first two revolutions of a hand wheel or when the stem of the valve has moved one fifth of the distance from its normal position. The signal shall not be restored at any valve position except the normal position.

Findings:

During document review and interview with the Director of Plant Operations (DPO) and Engineering staff (ENG1) on 2/29/16 through 3/3/16, documents were reviewed, and the Post Indicator Valves (PIV) were tested by staff.

1. On 3/1/16, between 12:35 p.m., and 1:40 p.m., during the testing of the three PIVs with facility staff, the valves were closed separately and the panel displayed a trouble signal. There was no distinct audible signal at the panel to alert staff that the PIVs were in trouble mode or being tampered with. The remote annunciator panel was located in the Admitting Front Office, and was constantly attended area.

2. On 3/1/16, at 2:05 p.m., the facility provided an annual report dated 3/20/15, documenting two PIVs were tested and passed. The facility has three PIVs.

3. On 3/1/16, at 2:11 p.m., the facility provided documentation for the quarterly inspection and testing of the PIVs by facility staff. The documentation was incomplete and only noted one PIV and one tamper switch were inspected quarterly. During interview, the ENG1 stated that the PIVs were visually inspected and not tested.



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4. On 3/1/16, at 12:40 p.m., the PIV tamper switch, located on the North side of the building by Riser #1 and closest to 215th Street, was tested and failed to send a supervisory signal to the remote annunciator, to the Admitting Area, and to the FACP in the Office by the Lobby. During the review of the monitoring stations activity report, the supervisory signal was not listed as being received.

The above findings were acknowledged during the exit conference on 3/3/16 by the Chief Executive Officer, the Chief Financial Officer, and the Director of Plant Operations.

Based on observation, the facility failed to maintain their automatic sprinkler system. This was evidenced by incomplete documentation for the quarterly testing of the Inspector's Test Valves (ITV) and the Post Indicator Valves (PIV), by sprinkler heads with debris, by sprinkler heads that were obstructed, by one of two Inspector's Test Valve that failed to activate the fire alarm system alarms within 90 seconds, by three Post Indicator Valves that were not labeled to identify the areas they controlled, and by escutcheon rings around sprinkler heads that were not flush against the ceiling surface. This could result in the failure of the sprinkler system. This affected 9 of 9 fire/smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

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

NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition
3-2.7.2* Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.
3-8.3 Identification of Valves. All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain, or other approved means.
5-5.5 Obstructions to Sprinkler Discharge.
5-5.5.1* Performance Objective. Sprinklers shall be located so as to minimize obstructions to discharge as defined in 5-5.5.2 and 5-5.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard. (See Figure A-5-5.5.1.)
5-5.5.2* Obstructions to Sprinkler Discharge Pattern Development.
5-5.5.2.1 Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with 5-5.5.2.
5-14.1.1.12 Identification signs shall be provided at each valve to indicate its function and what it controls.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
2.2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

NFPA 72, National fire Alarm Code, 1999 Edition.
2-6.2* Initiation of the alarm signal shall occur within 90 seconds of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.

Findings:

During a tour of the facility with the Director of Plant Operations (DPO) and Engineering staff (ENG1) from 2/29/16 through 3/3/16, the sprinkler system was observed.

1. On 2/29/16, at 11:18 a.m., the two water-based sprinkler heads located above the cooking equipment in the kitchen contained an accumulation of grease around their fusible links and deflectors.

2. On 3/1/16, at 10:56 a.m., the sprinkler head located inside the Lost & Found Closet did not have an 18 inch clearance around the sprinkler head. The closet had items placed approximately 6 inches from to the sprinkler head ..

3. At 11:41 a.m., the Inspector's Test Valve ( ITV), testing valve used to simulate the waterflow of one activated sprinkler head, was flowed and failed to activate the fire alarm system within 90 seconds. The ITV activated the fire alarm system after allowing the water to flow for 115 seconds.

4. At 12:40 p.m., the three Post Indicator Valves ( PIV) , used the shutoff the water supply to the fire sprinkler system, located exterior to the North side of the building, were not labeled to identify the areas that each valve controls.

5. On 3/2/16, at 10:28 a.m., the escutcheon rings around sprinkler heads were not flush to the ceiling in the Intensive Care Unit.



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6. On 3/29/16, at 2:27 p.m., during the facility tour, the sprinkler escutcheon ring in the GI Lab storage room was observed not to be flush with the ceiling.

7. On 3/1/16, At 10:15 a.m., during document review, the facility provided an annual report for the inspection and testing for the two ITVs dated 3/20/15, the reports stated that the two ITVs passed. The documentation for the quarterly inspection and testing by facility staff for the two ITVs were provided. During interview, the ENG1 was asked if the two ITVs were tested and he stated he visually inspected the ITVs and did not conduct any testing.
The facility Policy was written as follows: "WATER FLOW ALARM DEVICES - IN ACCORDANCE WITH NFPA 13A 4-5.3 WATER FLOW ALARM DEVICES SHALL BE TESTED QUARTERLY."
"POST INDICATOR VALVES - IN ACCORDANCE WITH NFPA 13A 2-7.3.1 POST INDICATOR VALVES SHALL BE TESTED QUARTERLY."
"TAMPER SWITCHES - TAMPER SWITCHES SHALL BE TESTED QUARTERLY." The above policies were reviewed & revised on 7/2015.

8. On 3/2/16, at 10:08 a.m., the sprinkler escutcheon ring located above bed two, and the sprinkler escutcheon ring in the bathroom were observed not to be flush with the ceiling and exposed approximately 2 inches of sprinkler pipe in room 310.

9. On 3/2/16, at 10:09 a.m., the sprinkler escutcheon ring in the bathroom, was observed not to be flush with the ceiling and exposed approximately 2 inches of sprinkler pipe in room 308.

10. On 3/2/16, at 10:12 a.m., the sprinkler escutcheon ring located above bed three, was observed not to be flush with the ceiling and exposed approximately 2 inches of sprinkler pipe in room 307.

11. On 3/2/16, at 10:16 a.m., the sprinkler escutcheon ring in the bathroom, was observed not to be flush with the ceiling and exposed approximately 2 inches of sprinkler pipe in room 304.

The above findings were acknowledged during the exit conference on 3/3/16 by the Chief Executive Officer, the Chief Financial Officer, and the Director of Plant Operations.

Based on observation, the facility failed to maintain their fire extinguishers. This was evidenced by portable fire extinguishers that were to the floor, and by portable fire extinguishers not specific to the classification of the hazards in the rooms. This could delay the removal of the fire extinguishers from their mounts, and delay extinguishing a fire. This affected 2 of 9 smoke compartments.

NFPA 101, Life Safety Code, 1999 Edition.
9.7.4 Manual Extinguishing Equipment.
9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition.
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).
A-2-1 Conditions of Selection. (b) Health and Safety Conditions that Affect Selection.
When a fire extinguisher is being selected, consideration should be given to the health and safety hazards involved in its
maintenance and use, as described in items (1) through (8). (7) Halon extinguishers should not be used on fires involving
oxidizers, since they can react with the oxidizer.
2-2.1 Fire extinguishers shall be selected for the class(es) of hazards to be protected in accordance with the following subdivisions. (For specific hazards, see Section 2-3.)
2-3.2* Fire extinguishers provided for the protection of cooking appliances that use combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires.
3-1.2.2* Occupancy hazard protection shall be provided by fire extinguishers suitable for such Class A, B, C, D, or K fire potentials as might be present.

Findings:

During a tour of the facility with the Director of Plant Operations (DPO) from 2/29/16 through 3/3/16, the portable fire extinguishers were observed.

1. On 2/29/16, at 11:25 a.m., the silver colored portable fire extinguisher in the kitchen was not the Class K (used on fires for combustible cooking media) type. The manufacturer label had the following information: Amerex Model 260, 6-liter stored pressure, Classification 1-B:C, B (liquids grease), C (electrical equipment).

2. On 3/1/16, at 11:09 a.m., the red colored portable fire extinguisher in the Cardiopulmonary Room was a halon type that was not permitted in a room containing oxidizers that included portable oxygen cylinders. The manufacturer label had the following information: Classification 10-B:C, 5 l.b. (pounds), halon 1211 fire extinguisher, Bromochlorofluoromethane.

3. At 11:49 a.m., the red colored ABC type portable fire extinguisher in the Recovery Room was mounted above sixty inches. The fire extinguisher was located by the Nurse Station, and measured approximately 67 inches from the floor to the handle.

4. At 4:19 p.m., the red colored ABC type portable fire extinguisher in the dirty side of the Central Service Room was mounted above sixty inches. The fire extinguisher measured approximately 65 inches from the floor to the handle.

The above findings were acknowledged during the exit conference on 3/3/16 by the Chief Executive Officer, the Chief Financial Officer, and the Director of Plant Operations.

Based on observation, record review, and interview, the facility failed to maintain their Commercial Cooking Equipment. This was evidenced by failing to install listed grease filters in their exhaust hood, and by failing to provide certification and final approval from the State's authority having jurisdiction in building construction for the installation of the kitchen suppression system. This could result in the failure of the kitchen fire suppression system in the event of a fire. This affected 1 of 9 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.6 Cooking Facilities. Cooking facilities shall be protected in accordance with 9.2.3.
9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.
4.5.6 System Design/Installation. Any fire protection system, building service equipment, feature of protection, or safeguard provided for life safety shall be designed, installed, and approved in accordance with applicable NFPA standards.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition
3-1 Grease Removal Devices. Listed grease filters, baffles, or other approved grease removal devices for use with commercial cooking equipment shall be provided. Listed grease filters shall be tested in accordance with UL 1046, Grease Filters for Exhaust Ducts. Mesh filters shall not be used.
7-6.2 Where a fire alarm signaling system is serving the occupancy where the extinguishing system is located, the activation of the automatic fire-extinguishing system shall activate the fire alarm signaling system.
7-9.1 Where required, complete drawing of the system installation, including the hood(s), exhaust duct(s), and appliances, along with the interface of the fire-extinguisher system detectors, piping, nozzles, fuel shutoff devices, agent storage container(s), and manual actuation device(s) shall be submitted to the authority having jurisdiction.
7-9.2 Installation of systems shall be performed only by persons properly trained and qualified to install the specific system being provided. The installer shall provide certification to the authority having jurisdiction that the installation is in agreement with the terms of the listing and the manufacturer's instructions and/or approved design.
7-10.1* Portable fire extinguishers shall be installed in kitchen cooking areas in accordance with NFPA 10, Standard for Portable Fire Extinguishers. Such extinguishers shall use agents that saponify upon contact with hot grease such as sodium bicarbonate and potassium bicarbonate dry chemical and potassium carbonate solutions. Class B gas-type portables such as CO2 and halon shall not be permitted in kitchen cooking areas. Manufacturer's recommendations shall be followed.

Findings:

During a tour of the facility with the Director of Plant Operations (DPO) from 2/29/16 through 3/3/16, the kitchen was observed, and documents for the installation of the fire suppression system in the kitchen were requested.

1. On 2/29/16, at 11:15 a.m., the kitchen hood exhaust system, located above the kitchen cooking equipment, contained four mesh filters that measured approximately 16 inches by 16 inches. The mesh type grease filters had no markings to show that they met UL 1046. The kitchen exhaust cleaning report, dated 2/2/16, noted that the grease catch pan in the plenum needed replacement.

2. At 11:40 a.m., the recently installed fire suppression system in the kitchen did not have final approval by the authority having jurisdiction in building construction, the Office of Statewide Health Planning and Development (OSHPD). The DPO was interviewed, stated that the plans submitted to OSHPD had been approved (OSHPD Project # S150437-19-00) on 1/22/16, a building permit had been issued (OSHPD BP# S150437-19-00-BPT01) on 2/1/16, and the installation documents showed that the system was installed per NFPA 17A, 2009 Edition, NFPA 96, 2011 Edition, and UL300, 2005 Edition. The Kitchen Suppression System Installer, C-10 License #341858 stated that the installation had been completed. The DPO was interviewed, and stated that the construction verification was needed by the Inspector of Records, IOR, (person responsible for maintaining contract documents and to verify the construction of the project) before OSHPD could issue final approval. The DPO provided a document titled "Testing, Inspection and Observation Program," that did not include construction verification signatures for all required tests, including electrical shutdown, gas shutdown, and acceptance test. The DPO stated that the facility has assigned security staff to conduct fire watch rounds in the kitchen every 30-minutes since 1/20/16 until the suppression system was approved. The OSHPD Citizen Access web page showed that the project was pending field operations verification.

The above findings were acknowledged during the exit conference on 3/3/16 by the Chief Executive Officer, the Chief Financial Officer, and the Director of Plant Operations.

Based on observation, the facility failed to ensure that all means of egress were continuously maintained free of obstructions to full instant use in the case of fire or other emergency. This was evidenced by obstructions found along egress pathways. This could result in a delay in evacuation in the event of a fire, or other emergency. This affected 2 of 15 exit routes.

NFPA 101, Life Safety Code, 2000 Edition
18.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
7.7.1 Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.

Findings:

During a tour of the facility with the Director of Plant Operations (DPO) from 2/29/16 through 3/3/16, the egress paths were observed.

1. On 2/29/16, at 2:47 p.m., the exterior pathway from Unit 3 North exit door, located by Riser#2, was not maintained clear of obstructions. The width of the pathway was narrowed by shrub and bushes growing into the paved walkway.

2. On 3/2/16, at 8 a.m., the exterior pathway from the Operating Rooms East exit door was not protected against obstructions from construction debris. The pathway had piles of dirt along the side of the paved walkway that could result in mud flows in the path during rain. The DPO had no knowledge of the construction debris that appeared to have been produced by a trench created from the building towards the bulk oxygen tank enclosure. The Office of Statewide Health Planning and Development, OSHPD, (State authority having jurisdiction in building construction) Citizen Access web page showed a Replacement Bulk Oxygen Tank Project (#S150508-19-00) that had been closed due to inactivity. The OSHPD web page showed no Building Permit issued for this project, no construction start date assigned, and no plan approvals with remarks letter sent since 5/19/15.

The above findings were acknowledged during the exit conference on 3/3/16 by the Chief Executive Officer, the Chief Financial Officer, and the Director of Plant Operations.

Based on observation, the facility failed to maintain their compressed gas cylinders. This was evidenced by two carbon dioxide cylinders that were not individually secured. This could cylinder damage and explosion or fire. This affected 1 of 9 fire/smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.4
Medical Gas.
Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
4-3.1.1.1. Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Findings:

During a tour of the facility with the Director of Plant Operations (DPO) from 2/29/16 through 3/3/16, the compressed gas cylinders were observed.

On 2/29/16, at 11:34 a.m., the two carbon dioxide cylinders, located in the kitchen by the dishwashing area, were found standing upright and unsecured. Each cylinder had a stamped 33.12 T.W. (Tare Weight in pounds).

The above findings were acknowledged during the exit conference on 3/3/16 by the Chief Executive Officer, the Chief Financial Officer, and the Director of Plant Operations.

Based on document review and interview, the facility failed to maintain the generator in accordance with NFPA 110, as evidenced by failing to exercised the emergency generator under load conditions for a continuous 30 minutes once a month. This had the potential for generator failure and affected residents in 9 of 9 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
9.1.3 Emergency Generators. Emergency generators, where
required for compliance with this Code, shall be tested and
maintained in accordance with NFPA 110, Standard for Emergency
and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
6-4 Operational Inspection and Testing.
6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
6-4.2 Generators sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperatures 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.
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.

Findings:

During document review, and interview with the Director of Plant Operations (DPO), Engineering staff (ENG1) and (ENG2) from 2/29/16 through 3/3/16, the generator maintenance and testing logs were reviewed.

1. On 3/1/16, at 11:00 a.m., the documentation provided by the facility for the emergency generator monthly load test from January 2015 through December 2015, indicated the generator was exercised for approximately 18 minutes once a month, and was exercised for 45 minutes with no load once a month. The documentation also indicated there were two power outages in March 13, 2015, when the generator ran under load for approximately 40 minutes, and a power outage on June 25, 2015, when the generator ran under load for 54 minutes.

2. On 3/2/16, at 8:41 a.m., during interview, ENG1 and ENG2, stated that the generator was exercised under load for approximately 18 minutes. ENG1 confirmed the generator was exercised once a month for 45 minutes including cool down time without a load.

3. On 3/3/16, at 9:15 a.m., the DPO provided a four hour load bank test dated 1/9/16, by an outside provider.

The above findings were acknowledged during the exit conference on 3/3/16 by the Chief Executive Officer, the Chief Financial Officer, and the Director of Plant Operations.

Based on observation, the facility failed to maintain their electrical safety. This was evidenced by appliances plugged into power strips, by power strips that were daisy chained (interconnection of electrical devices in sequence), and by the use of unauthorized electrical adapters. This could overload the electrical system and could result in an electrical fire. This affected 6 of 9 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
Section 9.1 Utilities
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition
400-8. Uses not permitted.
Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for a fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Findings:

During the facility tour with Director of Plant Operations (DPO) and Engineering staff (ENG1) from 2/29/16 through 3/3/16, the electrical equipment and devices were observed.

1. On 2/29/16, at 2:10 p.m., there was a three outlet adapter plugged into a power strip in the Health Information Management (HIM) office.

2. On 2/29/16, at 2:17 p.m., there was a power strip plugged into an other power strip in the Coding Department office.

3. On 2/29/16, at 2:21 p.m., the refrigerator was plugged into a power strip and not directly into the wall outlet in the Medical Staff office.

4. On 2/29/16, at 2:23 p.m., the refrigerator was plugged into a power strip located behind the copy machine in the Case Management office.

5. On 2/29/16, at 3:03 p.m., the refrigerator and microwave were plugged into a power strip, and not directly into the wall outlet inside the employee break room.

6. On 3/1/16, at 11:57 a.m., the red emergency electrical outlet in the CYSTO room, was missing the bottom half of the faceplate.

7. On 3/1/16, at 11:59 a.m., the electrical outlet faceplate located next to the Steris processor in the surgery suite, was missing a corner piece of the faceplate.

8. On 3/2/16, at 11:14 a.m., there was a six outlet adapter plugged into the wall outlet. The findings were observed, and confirmed by staff during survey.








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9. On 3/1/16, at 10:31 a.m., there was electrical equipment daisy chained in the Stress Test Area inside the Physical Therapy Room. The electrical equipment included a light fixture above the counter top, that was connected to an extension cord, that was connect to a six outlet power strip, that was then connected to the duplex receptacle wall outlet.

10. At 11:05 a.m., there was electrical equipment daisy chained in the Blood Gas Lab Area inside the Cardiopulmonary Room. The electrical equipment included medical devices connected to an extension cord, that was connect to a four outlet relocatable power tap, that was then connected to the duplex receptacle wall outlet.

The above findings were acknowledged during the exit conference on 3/3/16 by the Chief Executive Officer, by the Chief Financial Officer, and the Director of Plant Operations.