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Based on visual observation the facility failed to assure that the exterior Exit door with hospital special locking hardware would release when the fire alarm is activated into alarm status. In cases of a fire alarm emergency the exterior Exit doors provide safe passage to all occupants in need of egress by releasing the magnetic hospital special healthcare locking and remaining unlocked for the duration of the emergency. The deficient practice had the potential to affect n/a of n/a patients.

Findings:

During the facility tour on May 12, 2021 between the hours of 9:00 a.m. to 3:30 p.m. and May 13, 2021 between the hours of 11:00 a.m. to 1:30 p.m. the off-site business occupancy identified as Compass Behavioral Center of Crowley located at 720 North Avenue L Crowley, La. 70526 had a cross corridor double door, located at the rear of the tenant space, utilizing a prohibited method of special care locking arrangement for a business occupancy. The cross corridor double door was a required exit access door and lacked a acceptable method of providing a properly functioning access control door arrangement as per NFPA 101:7.2.1.6.2.

NFPA 101:39.2.2.2.6 Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.


NFPA 101:7.2.1.6.2* Access-Controlled Egress Door Assemblies. Where permitted in Chapters 11 through 43, door assemblies in the means of egress shall be permitted to be equipped with electrical lock hardware that prevents egress, provided that all of the following criteria are met:
(1) A sensor shall be provided on the egress side, arranged to unlock the door leaf in the direction of egress upon detection of an approaching occupant.
(2) Door leaves shall automatically unlock in the direction of egress upon loss of power to the sensor or to the part of the access control system that locks the door leaves.
(3) Door locks shall be arranged to unlock in the direction of egress from a manual release device complying with all of the following criteria:
(a) The manual release device shall be located on the egress side, 40 in. to 48 in. (1015 mm to 1220 mm ) vertically above the floor, and within 60 in. (1525 mm) of the secured door openings.

Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor. Hazardous areas within a supervised sprinklered facility are required to be constructed to resist the passage of smoke and provide a door that self closes and self-latches properly. The deficient practice had the potential to affect nine of nine patients. There were two of three smoke compartments were separated from the hazardous areas.

Findings:

During the facility tour on May 12, 2021 between the hours of 9:00 a.m. to 3:30 p.m. and May 13, 2021 between the hours of 11:00 a.m. to 1:30 p.m. of the main psychiatric hospital occupancy soiled linen room corridor access door did not automatically close due to lacking a self closing device.

NFPA 101: 19.3.2.1 Hazardous Areas. 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 8.7.1.


NFPA 101: 19.3.2.1.1 An automatic extinguishing system, where used in hazardous areas, shall be permitted to be in accordance with 19.3.5.9.

NFPA 101:19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4.

NFPA 101: 19.3.2.1.3 The doors shall be self-closing or automatic-closing.

Interview with the administrator revealed the facility was not aware the hazardous area soiled linen room door was required to be self closing to allow the soiled linen room door to remain in the closed position at all times with exception of being accessed by staff personnel.

Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect n/a of n/a patients..

Findings:

During the facility tour on May 12, 2021 between the hours of 9:00 a.m. to 3:30 p.m. and May 13, 2021 between the hours of 11:00 a.m. to 1:30 p.m., the off-site business occupancy identified as Compass Behavioral Center of Lafayette located at the address 1015 St. John, Lafayette, LA 70501 had a trouble due to the secondary phone line not properly functioning.

NFPA 72: 10.3.2 System components shall be installed, tested, and maintained in accordance with the manufacturer's published instructions and this Code.

NFPA 72:10.4.1.2 State or local licensure regulations shall be followed to determine qualified personnel. Depending on state or local licensure regulations, qualified personnel shall include, but not be limited to, one or more of the following: (1) Personnel who are registered, licensed, or certified by a state or local authority.

The interview with facility manager revealed the facility was aware of the fire alarm trouble and was awaiting the fire alarm a licensed technician to service the fire alarm system.

Based on observation, records review, and interview, the facility failed to have a licensed sprinkler suppression agent complete a five year Microbiologically Influenced Corrosion inspection of the sprinkler system internal piping. The deficient practice affected nine of nine patients.

The findings include:

During the facility tour on May 12, 2021 between the hours of 9:00 a.m. to 3:30 p.m. and May 13, 2021 between the hours of 11:00 a.m. to 1:30 p.m. of the main psychiatric hospital occupancy revealed the facility did not have records of five (5) year MIC testing of internal piping of sprinkler system nor did the facility have quarterly inspection documentation of the sprinkler system.

NFPA 25: 4.3.1* Records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.
NFPA 25: 4.3.2 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
NFPA 25: 4.3.3* Records shall be maintained by the property owner.
NFPA 25: 14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material.
NFPA 25: 14.2.1.1 Alternative nondestructive examination methods shall be permitted.
NFPA 25: 14.2.1.2 Tubercules or slime, if found, shall be tested for indications of microbiologically influenced corrosion (MIC).
NFPA 25: 14.2.1.3* If the presence of sufficient foreign organic or inorganic material is found to obstruct pipe or sprinklers, an obstruction investigation shall be conducted as described in Section 14.3.
NFPA 25: 14.2.1.4 Non-metallic pipe shall not be required to be inspected internally.
NFPA 25: 14.2.1.5 In dry pipe systems and pre-action systems, the sprinkler removed for inspection shall be from the most remote branch line from the source of water that is not equipped with the inspector's test valve.
NFPA 25: 14.2.1.6* Inspection of a cross main is not required where the system does not have a means of inspection.
NFPA 25: 14.2.2* In buildings having multiple wet pipe systems, every other system shall have an internal inspection of piping every 5 years as described in 14.2.1.

The interview with the administrator revealed the facility was not aware of the requirement for five (5) year MIC inspection for the sprinkler system internal piping nor was the facility aware a quarterly documented inspection is required to be conducted by a qualified individual.