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The facility failed to maintain a permitted building type per code for a building without a sprinkler system. Findings include:

During the survey, the following are examples of what was observed:

1. The HVAC ceiling registers did not have fire dampers.
2. Patient rooms 307 - 316 - the light fixtures were not tented.
3. Rooms in the original building - the plaster ceiling above the lay-in ceiling had several penetrations throughout the building.
4. The Med. Room had an unsealed ceiling penetration above the door.





1999 NFPA 90A, 3-4.4 Ceiling dampers or other methods of protecting openings in rated floor- or roof-ceiling assemblies shall comply with the construction details of the tested floor- or roof-ceiling assembly or with listed ceiling air diffusers or listed ceiling dampers. Ceiling dampers shall be tested in accordance with UL 555C, Standard for Safety Ceiling Dampers.
2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
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The facility failed to provide corridor walls that would provide at least a 30 minute fire resistance rating. Findings include: During the survey, the following are examples of what was observed:


1. Unsealed penetrations around conduit and a water line in the corridor wall by Patient Room 108.

2. Unsealed penetrations around a support channel in the corridor wall by Patient Room 99.

3. Unsealed penetrations at the deck of the corridor wall by Room 97.

4. The corridor wall did not extend to the deck by Patient Rooms 200, 202, 204, nor by Utilization Management office.


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5. The corridor wall at room 92 Surgery had unsealed penetrations of pipes and wires above this corridor door.



NFPA 101, 19.3.6.1 Corridors in unsprinklered smoke compartments shall be separated from all other areas by partitions having a fire resistance rating of at least 30 minutes.

2000 NFPA 101, 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
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The facility failed to maintain the corridor openings per code. Findings include:
During the survey, the following are examples of what was observed:

1. The Restroom door # 205 was not provided with positive latching hardware.

2. Auto Clay Room Hall 200 door was not provided with positive latching hardware.

3. Patient Room 101 had two holes approximately the size of a dime in the door above the handle.

4. Patient Room 105 had a hole approximately the size of a quarter in the door to the right of the handle.

5. The Dictation Room Hall 100 door was not provided with positive latching hardware.


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6. Room 94 Radiology - corridor door was missing the glass panel.

7. The following corridor doors did not have positive latching hardware:

a. Room 94 Radiology
b. Room 202
c. Room 204
d. Room 109
e. The room next to room 116
f. Room 94A
g. Room 94B

8. The following rooms had wedges holding open the corridor doors:

a. Room 94A
b. Room 94B




2000 NFPA 101, 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 13/4-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.
2000 NFPA 101, 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.
2007 CMS - 2786R There is no impediment to the closing of the corridor doors.

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The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include:
During the survey, the following is an example of what was observed:

Unsealed penetrations around a group of wiring in the Smoke Barrier by Patient Room 102.



NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

The facility failed to maintain the hazardous areas per code. Findings include:
During the survey, the following are examples of what was observed:

The Boiler Room had a gas fueled water heater -

a. The ceiling had several holes and unsealed penetrations
b. The right wall had an unsealed penetration of wires




2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded 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:
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The facility failed to maintain the two hour fire barrier per code. Findings include:
During the survey, the following are examples of what was observed:

1. The two hour fire barrier at room 90 CT Scan had the following unsealed penetrations:

a. A bunch of grey, red, and black wires, to the left.
b. A hole above a grey pipe
c. The end of the grey pipe
d. Two red wires to the right.

2. The two hour fire barrier in room 90 CT Scan had the following unsealed penetrations:

a. Several conduits to the right of the fire alarm device.
b. One conduit and one tan wire, far end of wall




2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met: a. The material shall be capable of maintaining the fire resistance of the fire barrier. b. The material shall be protected by an approved device that is designed for the specific purpose. (4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the fire barrier. b. It shall be made by an approved device that is designed for the specific purpose.

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The facility failed to provide continuous lighting for means of egress. Findings include: During the survey, the following are examples of what was observed:


1. The Exit for Hall 100 light fixture, at the Exit Discharge, is controlled by a switch located in the corridor.

2. The Exit for Hall 300 light fixture, at the Exit Discharge, is controlled by a switch located in the corridor.





NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.


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The facility failed to provide a fire safety plan. Findings include:
During the survey, the following is an example of what was observed:

The facility was not able to provide a written fire safety plan.




NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following: (1) Use of alarms, (2) Transmission of alarm to fire department, (3) Response to alarms, (4) Isolation of fire, (5) Evacuation of immediate area, (6) Evacuation of smoke compartment, (7) Preparation of floors and building for evacuation, and (8) Extinguishment of fire.

The facility failed to conduct fire drills per code. Findings include:
During the survey, the following are examples of what was observed:

1. Per documentation from the facility, the fire drills were not held at unexpected times (varying condictins) on all three shifts (see below).
2. Per documentation from the facility, the day of the month was not documented (see below).
3. Per documentation and interview with staff, the staff is not signing the fire drills, indicating participation.

FIRST SHIFT
03/2011 - 8:30A
12/2010 - 10:45A
09/2010 - 8:30A
06/2010 - 8:30A

SECOND SHIFT
04/15/11 - 5:30P
01/2011 - 5:00P
10/2010 - 4:15P
07/2010 - 4:45P
04/2010 - 4:30P

THIRD SHIFT
02/2011 - 6:30A
11/2010 - 6:00A
08/2010 - 6:30A
05/2010 - 6:00A





2000 NFPA 101, 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.

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Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include:
During the survey, the following are examples of what was observed:

1. When the Auto Dialer was tested for phone line 1, failure was not indicated at the protected premise within the allotted four (4) minute time frame. (Surveyor waited 5 minutes.)

2. When the Auto Dialer was tested for phone line 2, failure was not indicated at the protected premise within the allotted four (4) minute time frame. (Surveyor waited 5 minutes.)

3. When the Auto Dialer was tested for Communication Failure, failure was not indicated at the protected premise within the allotted fifteen (15) minute time frame (5 minimum to 10 maximum attempts for signal transmission). (Surveyor waited 16 minutes.)




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The facility failed to provide documentation of the inspection of the fire alarm system.
Findings include: During the survey, the following is an example of what was observed:

The facility was not able to provide documentation for the annual inspection of the fire alarm system. Based on interview with the Maintenance Director, and letter of COC from ADPH dated 9/22/2008, which he provided, the alarm has not been inspected since it was installed.





NFPA 101, 9.6.1.4 The fire alarm system to be installed, tested, and maintained in accordance with the requirements of NFPA 70 and NFPA 72.

The facility failed to perform sensitivity testing of the smoke detectors. Findings include: During the survey, the following is an example of what was observed:

Documentation provided by the facility, during the survey, did not indicate sensitivity testing of the smoke detectors.

Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).


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The facility failed to perform the required maintenance of the facility sprinkler system. Findings include:
During the survey, the following is an example of what was observed:

Documentation provided, during the survey, indicated quarterly sprinkler system inspections were last conducted on 5/19/2009.




NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).


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The facility failed to maintain the fire extinguishers per code. Findings include:
During the survey, the following are examples of what was observed:

1. All fire extinguishers throughout the building, per documentation, indicated the last annual inspection as Sept. 2008.

2. The fire extinguishers at the following locations:

a. Room 99
b. Room 305
c. Room 201

had the following documentated monthly inspection dates:

10/08 04/09
11/08 05/09
12/08 06/09
01/09 07/09
02/09 08/09
03/09 04/11

3. The fire extinguisher in the Radiology Room between rooms 94A and 94B had the following documented monthly inspection dates:

10/08 02/09
11/08 03/09
12/08 04/09
01/09

4. The fire extinguisher in the Boiler Room did not have any monthly inspections documented.




1998 NFPA 10, 4-3.2 Periodic inspection of fire extinguishers shall include a check of at least the following items: (a) Location in designated place, (b) No obstruction to access or visibility, (c) Operating instructions on nameplate legible and facing outward, (d) Safety seals and tamper indicators not broken or missing, (e) Fullness determined by weighing or "hefting", (f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle, (g) Pressure gauge reading or indicator in the operable range or position, (h Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units), (i) HMIS label in place
1998 NFPA 10, 4-3.4.1 Personnel making inspections shall keep records of all fire extinguishers inspected, including those found to require corrective action.

1998 NFPA 10, 4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

1998 NFPA 10, 4-3.1* Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

1998 NFPA 10, 4-4.1 Frequency. Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

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The facility failed to maintain the means of egress per code. Findings include:

During the survey, the following are examples of what was observed:

1. A cart, a bed table, and a wheel chair were in the corridor outside room 202 for over 30 minutes.
2. Two chart carts were in the corridor at the Nurses' Station over three hours.
3. Two med. carts were in the corridor outside room 96 during the entire survey.
4. The OR Manager's Office had a hasp with a padlock on it. The Manager was gone and no one could unlock the door.




2000 NFPA 101, 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.
2000 NFPA 101, 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.
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The facility failed to provide documentation of flame resistance per code. Findings include:

During the survey, the following is an example of what was observed:

The facility failed to provide documentation of flame resistance on the curtains/draperies throughout the building.




2000 NFPA 101, 10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.
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During the survey, the following is an example of what was observed:

Two oxygen cylinders were observed unsecure in the Mail Room Hall 200.




1999 NFPA 99, 4-3.1.1.1 and 4-5.1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.


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During the survey, the following is an example of what was observed:

The remote for the generator was inoperable, when generator was transfered under load by the Maintenance Director, the remote annuciator panel did not indicate under load. This surveyor requested the "auto switch" be placed in the off position, no alarm was indicated at the remote annuciator panel.





1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the Generating Room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.) The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]
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The facility failed to maintain the electrical system per code. Findings include:
During the survey, the following is an example of what was observed:

1. Old Boiler Room had covers missing on three junction boxes.

2. Surge protector plugged into a surge protector in the Doctors' Dictation Office Hall 200.


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3. A junction box above the door in the Med. Room was missing its cover plate.


NFPA 101 Life Safety Code (Sec. 19-5.1) Utilities shall comply with NFPA 101 (Sec. 9-1.). Electrical shall comply with the NFPA 70 National Electrical Code.

1999 NFPA 70, 370-28. Pull and Junction Boxes Boxes and conduit bodies used as pull or junction boxes shall comply with (a) through (d). (c) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception



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The facility failed to provide an automatic sprinkler sytem fire watch policy per code. Findings include: During the survey, the following is an example of what was observed:

The facility failed to provide an automatic sprinkler system fire watch policy.




2000 NFPA 101, 9.7.6.1 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.
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The facility failed to provide a fire alarm fire watch policy per code. Findings include:
During the survey, the following is an example of what was observed:

The facility failed to provide a fire alarm fire watch policy.




2000 NFPA 101, 9.6.1.8 Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.