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Based on observations, the facility failed to maintain the fire resistance rating of the 2-hour fire rated assemblies including walls/barriers in accordance with NFPA 101, 2000 Edition, Section 8.2.3.2.4.2. These deficiencies affect 1 of 2 main floor smoke compartments.

Findings include:

1. During an observation on 6/14/16 at 2:56 p.m., an unsealed, open ended conduit extended through the Emergency Room 2-hour fire rated assembly above the ceiling tiles.¹

2. During an observation on 6/14/16 at 3:02 p.m., an unsealed corner conduit penetration extended through the 2-hour fire rated assembly above the ceiling tiles, above the fire rated double doors next to the reception area.¹

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 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.

Based on observation, the facility failed to ensure prevention of impediments to closing of the exit corridor doors in accordance with NFPA 101, Section 18.3.6.3.3. This deficiency affects 1 of 2 main floor smoke compartments.

Findings include:

During an observation on 6/14/16 at 1:05 p.m., the exit corridor door to the Pharmacy was blocked open with a rubber chock.¹

¹ NFPA 101, 2000 Edition, Section 18.3.6.3.3 Hold-open devices that release when the door is pushed or pulled shall be permitted. A.18.3.6.3.3 Doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Based on observation, not all penetrations between floors were sealed limiting the transfer of smoke from one smoke compartment to another. This deficiency affects one main floor and the second floor smoke compartment.

Findings include:

During an observation of the mechincal penthouse on the second level, on 6/14/15 at 1:40 p.m., three unsealed conduit penetrations extended through the concrete floor near the north wall of the penthouse, by the heating pumps. Penetrations between the penthouse and main level of the building must be sealed to limit the transfer of smoke between the two levels.

Based on observation, the facility failed to maintain the one-hour fire/smoke rated assemblies in accordance with NFPA 101, 2000 Edition, Section 18.3.7.3. This deficiency affects 1 of 2 smoke compartments.

Findings include:

During an observation on 6/15/16 at 9:45 a.m., two open ended conduits extended through the 1-hour rated smoke barrier above the Prep/Recovery doors, above the ceiling tiles.¹

¹ NFPA 101, 2000 Edition, Section 18.3.7.3; 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 hour.
Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2*: Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems.

Based on observations, the facility failed to protect hazardous areas per NFPA 101, 2000 Edition, Section 18.3.2.1, by not assuring penetrations trough barriers were maintained an one hour rating. These deficiencies affect 1 of 2 main floor smoke compartments.

Findings include:

1. During an observation on 6/15/16 at 9:10 a.m., the 1-hour corridor wall between storage and loading dock, above the ceiling tiles, had one open tip (unsealed)conduit with a white cable extending through it.

2. During an observation on 6/15/16 at 9:20 a.m., The 1-hour wall of the soiled linen room corridor wall had an unsealed open ended conduit penetration above the ceiling tiles. Additional penetration on this corridor wall measured approximately 16 cm by 13 cm. This penetration was previously repaired, but recently reopened. The pink colored insulation along with two green colored cables were exposed and extended through this hole.

Based on record review and interviews, the facility failed to conduct fire drills at a minimum of quarterly on each shift per NFPA 101, 2000 Edition, Section 18.7.1.2. This deficiency affects all main floor and second floor smoke compartments.

Findings include:

Review of facility fire drill documents reflected only the date of the fire drills were captured in the records. Fire drills lacked information during what time of the shifts they were conducted, what the simulated fire emergency was, and who attended the drills. The documentation also lacked if the fire alarm was initiated.¹

During an interview on 6/14/16/15 at 3:40 p.m., staff member B, described an evacuation drill, not a fire drill when he was asked about the drill procedures.

¹ NFPA 101, 2000 Edition, Section 18.7.1.2; 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.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Based on record review, the facility failed to ensure fire alarm control panel installation certificate was authorized as to its completion per NFPA 72, 1999 Edition, Sections 7-5.1, 7-5.2.1 and 7-5.2.2. This deficiency affects all smoke compartments on both floors.¹

Findings include:

1. Review of the 11/17/15 Fire Alarm System Record of Completion reflected the following deficiencies:
a.) The document was not authorized (lacking signatures) and dated by the System Service Contractor, Central Station, the Property Representative on page 5;

b.) The document also lacked the property representative address, phone, fax and email; and, the contracted testing company's address, phone, fax, email on the first page; and

c.) The document lacked information in Section 8.1, Emergency Voice Alarm Service on page 3. All aforementioned areas were left blank on the document, and did not show if the information was "Not Applicable" in those sections.

¹ NFPA 72 National Fire Alarm Code, 1999 Edition, Section 7-5.1; After successful completion of acceptance tests approved by the authority having jurisdiction, a set of reproducible as-built installation drawings, operation and maintenance manuals, and a written sequence of operation shall be provided to the building owner or the owner ' s designated representative. The owner shall be responsible for maintaining these records for the life of the system for examination by any authority having jurisdiction. Paper or electronic media shall be permitted.

² NFPA 72, 1999 Edition, Section 7-5.2.1; Records shall be retained until the next test and for 1 year thereafter.

³ NPFA 72, 1999 Edition, Section 7-5.2.2; A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) * Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

Based on record review and interview, the facility failed to conduct load voltage tests on the batteries of the fire alarm control panel (FACP) semiannually as required per NFPA 72, 1999 Edition, Table 7-3.2. The deficiency affects all main and second floor smoke compartments.

Findings include:

Review of the FACP test records reflected the system was installed on 11/17/15. The load voltage testing was not completed six months after the installation in May of 2016.¹

During an interview on 6/15/16 at 12:50 p.m., staff member B stated he was neither aware of the requirement nor did he provide documentation verifying the load voltage tests were conducted every six months.

¹ NFPA 72, 1999 Edition, Table 7.3.2 (6)(d)(3), requires sealed lead-acid type batteries to have a "Load Voltage Test" upon initial installation and then semiannually thereafter.

Based on record review and interview, the facility failed to maintain the fire alarm system maintenance documents in accordance with NFPA 72, 1999 Edition, Section 7-3.2.1¹ and 7-5.2.1². The deficiency affects all main floor and second floor smoke compartments.

Findings include:

Review of the facility's maintenance records reflected a lack of the initial installation sensitivity testing records for the smoke detectors and when the alarm system was first approved on 11/17/15.¹ A hard copy or the ability to print an electronic version of the smoke detector sensitivities shall be ready for review when requested.²

During an interview on 6/15/16 at 10:50 a.m., staff member B stated he would contact the service provider and ask for the documentation. The service provider confirmed the printout was not available, but he would visit the facility and print the sensitivities of the smoke detectors that day on 6/15/16.

¹ NFPA 72 National Fire Alarm Code, 1999 Edition, Section 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.

² NFPA 72, 1999 Edition, Section 7-5.2.1; Records shall be retained until the next test and for 1 year thereafter.

Based on observations, record review and interview, the facility failed to ensure the integrity of the automatic sprinkler system was continuously maintained, inspected and tested periodically in accordance with NFPA 25, 1998 Edition, Table 2-1 and NFPA 13, 1999 Edition, Section 3-2.9.2 and 5-1.1. These deficiencies affect all main floor and second floor smoke compartments.

Findings include:

1. Review of the automatic sprinkler maintenance records showed a missing maintenance action for the first quarter of 2016.¹ The system was installed and certified in October of 2015. The next maintenance record was dated 5/27/16. During an interview on 6/14/16 at 4:30 p.m., staff member B stated contract negotiations took longer than they desired.

2. During an observation on 6/14/16 at 11:47 a.m., a lay-in ceiling tile was removed from its track, exposing a hole in the ceiling in the Clean/Sterile Processing room.²

3. During an observation on 6/14/16 at 2:14 p.m., the box for the spare sprinkler heads lacked a wrench.³

¹ NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition, Table 2-1, quarterly inspections of alarm devices & hydraulic nameplate and testing of alarm devices and main drain.

² NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-1.1; The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
Exception No. 3: Clearance between sprinklers and ceilings exceeding the maximum specified in 5-6.4.1, 5-7.4.1, 5-8.4.1, 5-9.4.1, 5-10.4.1, and 5-11.4.1 shall be permitted provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections.

³ NFPA 13, Section 3-2.9.2; A special sprinkler wrench shall also be provided and kept in the cabinet to be used in the removal and installation of sprinklers.

Based on observation, the facility failed to store oxygen cylinders in accordance with the standards of NFPA 99, 1999 Edition, Section 4-3.5.2.1.¹ These deficiencies affect 1 of 2 smoke compartments.

Findings include:

1. During an observation on 6/14/16 at 10:30 a.m., two K size oxygen cylinders were chained around the neck of the cylinders and were not secured tightly to prevent them from tipping over.¹

2. During an observation on 6/15/16 at 1:38 p.m., staff member B measured the electrical outlet distances to the floor in the master oxygen manifold room. The tops of the two 2-receptacle cover plug outlets (for the generator - red) were at 60 inches.² The tops of the other two outlets were at 62 inches. The outlets were located on the east and south walls of the room. The two, 8-bank, K size oxygen cylinders and the manifold were located on the north wall of the room.

¹ NFPA 99 Standard for Health Care Facilities, 1999 Edition, Section 4-3.5.2.1; Gases in Cylinders and Liquefied Gases in Containers - Level 1, (a) Handling of Gases; requires 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.
² NFPA 99, 1999 Edition, Section 4-3.1.1.2(a)4; The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.

Based on record review, the facility failed to have evidence that the generators were consistently inspected weekly in accordance with NFPA 110, 1999 Edition, Section 6-4.1 and failed to document the monthly load test run times per NFPA 110, 1999 Edition, Section 6-3.4. These deficiencies affect all main and second floor smoke compartments.

Findings include:

1. Review of the generator maintenance records showed the following deficiencies:
a.) A consistent date and staff initials when the 30 minute monthly loads tests were conducted;¹ ² and
b.) The documentation lacked the run times and the weekly visuals of the generator since the hospital opened on 12/12/16.¹ ²

¹ NFPA 110 Standard for Emergency and Standby Power Systems, 1999 Edition, Section 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.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.

² NFPA 110, 1999 Edition, Section 6-3.4; A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer

Based on review of the fire plan, the facility failed to have a fire watch policy which included one of the authorities having jurisdiction (State Agency) being contacted whenever it was instituted per NFPA 101, 2000 Edition, Section 9.7.6.1. This deficiency would affect all main floor and second floor smoke compartments.

Findings include:

Review of the fire plan showed a lack of the procedures to be followed whenever the automatic sprinkler system was out of service for more than 4 hours in a 24-hour period. The fire watch policy did not specifically include notification of the State Agency at 406-444-4170 whenever the sprinkler system was out of service for longer than 4 hours in 24 hour period.

Based on review of the fire plan, the facility failed to have a fire watch policy which included one of the authorities having jurisdiction (State Agency) being contacted whenever it was instituted per NFPA 101, 2000 Edition, Section 9.6.1.8. This deficiency would affect all main floor and second floor smoke compartments.

Findings include:

Review of the fire plan showed a lack of the fire watch policy and procedures to be followed whenever the fire alarm system was out of service. The policy did not specifically include notification of the State Agency at 406-444-4170 whenever the fire alarm system was out of service for more than 4 hours in a 24 hour period.