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The facility failed to provide the a building construction type per code. Findings include:

During the survey, the following is an example of what was observed:
Fifth Floor of a six story building
An unprotected I-beam (structural member) was oberved in the area of Nurses' Station ICT 1 and the locker room behind the Nurses' Station

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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 maintain the corridor openings per code. Findings include:

During the survey, the following is an example of what was observed:
Fifth Floor
Central Monitoring Room's corridor door had a self-closing device on it, but was being held open by a wedge

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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:

1. Unsealed penetrations around conduit in the Smoke Barrier, of the Administrative Corridor.


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Fifth Floor
2. The smoke barrier at the corridor wall for ICT Supply Room was not sealed at the corrugated deck
Second Floor
3. The smoke barrier at doors 2-6 at Respiratory Hallway was not sealed at the right corner above the HVAC duct
Third Floor
4. Unsealed pipe penetration at doors 3-1 at room 338

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2000 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.

2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows: (1) The space between the penetrating item and the smoke partition shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. 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 smoke partition, the sleeve shall be solidly set in the smoke partition, 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 limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the smoke partitions. b. It shall be made by an approved device that is designed for the specific purpose.
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The facility failed to maintain separation of hazardous areas. Findings include: During the survey, the following is an example of what was observed:

Unsealed penetrations around conduit in the wall of the Mechanical Room (GFB), Ground Floor.
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NFPA 101, 19.3.2.1 and 8.4.1 Hazardous areas to be provided with smoke-resisting partitions and doors when protection consists of an automatic extinguishing system. Doors shall be selfclosing with positive latching hardware.

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The facility failed to maintain stairways with at least 2 hour fire resistance rating. During the survey, the following is an example of what was observed:

Unsealed penetrations around a sprinkler line, in the wall of stairwell "B" Fourth floor.
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2000 NFPA 19.3.1.1 Any vertical openings shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than 2-hour fire resistance rating.
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The facility failed to conduct fire drills per code. Findings include:

During the survey, the following is an example of what was observed:
Per documentation and interview the facility was not getting the staff to sign the participation sheet

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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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The facility failed to provide a fire alarm system per code. Findings include:

During the survey, the following is an example of what was observed:
Ground Floor
While testing the fire alarm system, the Linen Room did not not have an audible or a visual fire alarm device in it and you could not hear the alarm in the room

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2000 NFPA 101, 9.6.1.9 For the purposes of this Code, a complete fire alarm system shall be used for initiation, notification, and control and shall provide the following. (a) Initiation. The initiation function provides the input signal to the system. (b) Notification. The notification function is the means by which the system advises that human action is required in response to a particular condition. (c) Control. The control function provides outputs to control building equipment to enhance protection of life.
2000 NFPA 101, 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.
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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:

While reviewing the documentation for the quarterly inspections of the sprinkler systems, conducted on 3/9/12, 6/21/12, and 9/18/12, indicated in the comment section that eight sprinklers located in the Ambulance Drive Through were Globe J-1999 recall sprinklers. Based on interview with the Assistant Director of Facilities Management these sprinklers have not been replaced.
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1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.

Every required sprinkler system shall be continuously maintained in proper operating condition. NFPA 101, 4.6.12.1.
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The facility failed to maintain the designated smoking areas per code. Findings include:

During the survey, the following are examples of what was observed:
The following designated smoking areas did not have the metal containers with self-closing covers:
1. Emergency Department
2. POB 1

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2000 NFPA 101, 19.7.4 Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. (2) Smoking by patients classified as not responsible shall be prohibited Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision. (3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
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The facility failed to maintain the cooking facilities per code. Findings include:

During the survey, the following is an example of what was observed:
Ground Floor
The kitchen hood was missing the grease catching pans

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1998 NFPA 96, 3-2.6 Filters shall be equipped with a drip tray beneath their lower edges. The tray shall be kept to the minimum size needed to collect grease and shall be pitched to drain into an enclosed metal container having a capacity not exceeding 1 gal (3.785 L).
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The facility failed to maintain the medical gas storage per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor
An unsecured oxygen cylinder was observed in the Dark Room
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1999 NFPA 99, 4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers - Level 1. (a) * Handling of Gases. Administrative authorities shall provide regulations to ensure that standards for safe practice in the specifications for cylinders; marking of cylinders, regulators, and valves; and cylinder connections have been met by vendors of cylinders containing compressed gases supplied to the facility. (b) Special Precautions - Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed: 27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
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This is a rewrite from the survey conducted in 2006. A waiver was issued until 2009 for this deficiency.

The facility failed to provide anesthetizing locations per code. Findings include:

During the survey, the following is an example of what was observed:
Per interview with the staff, the smoke venting systems were not installed for the four windowless ORs

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1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, " Electrical Systems. "
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1. The facility failed to maintain a fire alarm system with approved component devices or equipment installed to provide effective warning of fire in any part of the building. Findings include: During the survey, the following is an example of what was observed:

While testing the fire alarm the Audible/Visual device by H and G Stairwell Second Floor failed to function.
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2000 NFPA 101, 9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
2000 NFPA 101, 9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.




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2. The facility failed to maintain the following system per code. Findings include:

During the survey, the following is an example of what was observed:
Ground Floor (Cath. Lab.)
The automatic fire doors in the one hour rated tenant fire barrier separation, failed to become manual when the fire alarm was tested.

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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.

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The facility failed to maintain the electrical wiring and equipment per code. Findings include:

During the survey, the following are examples of what was observed:
Second Floor
1. EKG Room in ICU/Respiratory had a refrigerator plugged into a surge protector
Ground Floor
2. Network Administrator's Office had a refrigerator plugged into a surge protector

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1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

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