HospitalInspections.org

Based on facility record review and staff interview, the facility failed to maintain the contact information for all staff, entities providing services under arrangement, resident physicians and other hospitals, at least annually. Failure to have an emergency preparedness communication plan that includes specific information could lead to harm to both patients and/or staff during an emergency.

Findings include:

A review of the Haven Behavioral Hospital Emergency Operations Plan approved June 2024 and accompanying documentation revealed phone lists for key leaders and staff within the succession org chart only. No phone numbers for other staff could be found. No phone numbers for patients' physicians could be found. Although a transfer agreement exists with another hospital, no phone numbers for other hospitals or facilities could be found. No phone numbers of volunteers could be found.

In an interview conducted with Employees #3 and #4 on August 1, 2024, Employees #3 and #4 confirmed that additional phone numbers could not be found in the documentation provided to Compliance Officer.

Based observation, facilty documentation and interview, the Department has determined the facility failed to maintain at least a 2-hour fire resistant separation for the hospital from other occupancies. Failure to provide the minimum fire protection features could cause serious injury or death in the event of a fire.

NFPA 101: Life Safety Code, 2012 Edition - Chapter 19 Existing Health Care Occupancies
19.1.2 Classification of Occupancy.
6.1.5.1 * Definition - Health Care Occupancy.
An occupancy used to provide medical or other treatment or care simultaneously to four or more patients on an inpatient basis, where such patients are mostly incapable of self-preservation due to age, physical or mental disability, or because of security measures not under the occupants' control.
19.1.3.4 Contiguous Non-Health Care Occupancies.
19.1.3.4.1 * Ambulatory care facilities, medical clinics, and similar facilities that are contiguous to health care occupancies, but are primarily intended to provide outpatient services, shall be permitted to be classified as business occupancies or ambulatory health care facilities, provided that the facilities are separated from the health care occupancy by not less than 2-hour fire resistance-rated construction, and the facility is not intended to provide services simultaneously for four or more in patients who are litter borne.
19.1.3 Multiple Occupancies.
19.1.3.3 * Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions:
1. They are not intended to provide services simultaneously for four or more inpatients for purposes of housing, treatment, or customary access by inpatients incapable of self-preservation.
2. They are separated from areas of health care occupancies by construction having a minimum 2-hour fire resistance rating in accordance with Chapter 8.
3. For other than previously approved occupancy separation arrangements, the entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

NFPA 101 2012 Edition, Section 8.2 Construction and Compartmentation.

8.2.1.1 Buildings or structures occupied or used in accordance with the individual occupancy chapters, Chapters 11 through 43, shall meet the minimum construction requirements of those chapters.
8.2.1.2 * NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification.
8.2.1.3 Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on one of the following:
(1) Separate buildings, if a 2-hour or greater vertically aligned fire barrier wall in accordance with NFPA 221, Standard for High Challenge Fire Walls, Fire Walls, and Fire Barrier Walls, exists between the portions of the building.
(2) Separate buildings, if provided with previously approved separations.
(3) Least fire-resistive construction type of the connected portions, if separation as specified in 8.2.1.3(1) or (2) is not provided.

Findings include:

During observation while on tour conducted on August 1, 2024, after consulting blueprints and consulting the feedback of Employees #1 and #5, Compliance Officers observed a set of fire doors connecting Haven Behavioral Health to an outpatient health care occupancy on the second floor of the facility near the elevators. The fire wall was observed to stop at the top of the fire door assembly. Various wires and pipes were observed in the empty space above the fire door assembly connecting Haven Behavioral Health to the other occupancy.

Based on record review the facility failed to perform the monthly inspection for the facility's sprinkler systems. Failing to perform the required inspections may cause harm to patients and staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1. "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, 2011 Edition, "Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems." NFPA 25, 2011 Edition, "Water Based Extinguishment Systems," requires monthly, quarterly, and annual testing of automatic sprinkler systems.
Findings Include:

Observations while on tour August 01, 2024, revealed the facility failed to show proof of monthly testing of the sprinkler systems in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

Employees # 1, #3, and #5 confirmed during the exit conference that the facility did not have documentation verifying the required monthly testing of the sprinkler systems.

Based on record review and interview the facility failed to provide all required fire drills per NFPA 101. Failing to conduct fire drills in accordance with the life safety code one per shift per quarter to familiarize staff with conditions under an actual fire can result in harm to patients and/or staff during a an actual fire or emergency situation.

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.7.1.4* "Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions." Section 19.7.1.6 "Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions." Section 19.7.1.7 "When drills are conducted between 9:00 PM and 6:00 am a coded announcement shall be permitted to be used instead of audible alarms."

Findings include:

Based on record review and interview on August 1, 2024, revealed that the facility failed to conduct fire drills during the second shift for the entire past year.

During the exit conference on August 1, 2024, the above findings were again acknowledged by Employees # 1, #3, and #5.

Based on record review and interview, the facility failed to provide documentation of the annual fire door inspection. Failing to inspect and test fire-rated door assemblies annually could cause harm to the patients and/or staff.

NFPA 101 2012 Life Safety Code Section 8.3.3. Fire door and Windows Section 8.3.3.1 "Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening protective, except as otherwise specified in this code."

NFPA 80 Section 5.2* Inspections Section 5.2.1*"Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for the AHJ. Section 5.2.3 Functional Testing. Section 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing."

NFPA 80 Section 13.4 Automatic closing Section 5.2.5 Horizontal sliding, Vertically Sliding, and Rolling Doors.
Section 5.2.14.3 "All horizontal or vertical sliding or rolling fire doors shall be inspected and tested annually to check for proper operation at frequent intervals to ensure operation."

Findings include:

Based on record review and interview on August 01, 2024, revealed the facility failed to provide documentation for the 2023/2024 annual fire door inspections. The last documented fire door inspection was in 2020.

During the exit conference on August 01, 2024, the above findings were again acknowledged by Employees # 1, #3, and #5.