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Based on observation, the facility failed to maintain room finish and flame spread rating of Class A or Class B at all times.

Findings include:

On July 9, 2010, during a survey of the Hawthorne campus facility accompanied by engineering the evaluator observed a 4-inch diameter open pipe penetrating through the wall of the x-ray room.


14041

Western Campus

June 30, 2010, at 10:35 a.m., Third Floor, the evaluator observed two unsealed penetrations located in the ceiling for communication bunch of wires located in the ceiling. The unsealed penetrations measured approximately 1/2 inch to 1-1/2 inches in diameter.

June 29, 2010, Lower Level, there were two unsealed 1/4 inch penetration located in the Environmental Service Room.

An interview was held with the Building Manager and he stated that the unsealed penetration would be sealed as soon as possible.

Based on observation and interview, the facility failed to maintain the sealed construction for the corridor walls.

Finding:

Western Campus

On June 30, 2010 at 10:25 a.m., the evaluator inspected the 3rd floor Utility Room and observed two unsealed penetrations for the communication wires leading to the corridor. The penetrations measured approximately one inch and three inches.

An interview was held with the Building Engineer and he stated that the unsealed penetrations would be sealed as soon as possible.

Based on observation, the facility failed to maintain the corridor doors in a condition to resist the passage of smoke, free of obstructions to closing and with a means suitable for keeping the door closed. This is a repeat deficiency

Finding:

Los Angeles Campus

On June 29, 2010 the evaluator conducted an inspection of the facility 2nd floor Post Anesthesia Care Unit surgery room, the Scrub Room in Medical Surgery #1, and the Surgery Room #2. The evaluator observed that the corridor doors in these areas had a total of six-roller latching devices. Roller latches are prohibited by CMS regulations in all health care facilities. The evaluator also observed that the door leading to the surgery room was held open with a wooden door wedge. All these items were previously identified in an official Life Safety Code report dated November 20, 2010.

On July 6, 2010, at 10:00 a.m., the evaluator conducted an inspection of the facility and observed that the following corridors did not latch or close; 5th floor Nurse Station - 2-doors were removed from the medical storage room, 4th floor Clean Linen Storage corridor door #95 did not latch or close, and at the lower level, the Nuclear Medical Storage corridor door would not latch.

An interview was held with the Building Manager and he stated that the facility "needed more time" to get these items corrected.

On June 30, 2010, the evaluator inspected the kitchen double doors and observed that 1 of 2 doors remained slightly ajar with air rushing out of the kitchen doors.

An interview was held with the kitchen staff and he stated that door remained open because of the negative pressure.

Based on observation, the facility failed to ensure two magnetically held doors automatically closed upon activation of the fire alarm system.

Findings include;

On July 6, 2010 at 10:40 a.m., during a survey and test of the fire alarm system for the Los Angeles campus facility, the evaluator, accompanied by the engineering project coordinator, observed the magnetically held cross-corridor door on the first floor near the exterior stairs to the parking lot failed to automatically release and close upon activation of a smoke detector.

On July 7, 2010 at 12:31 p.m., during a survey and test of the fire alarm system for the Hawthorne campus facility, the evaluator, accompanied by engineering, observed the magnetically held corridor door in the kitchen basement failed to automatically release and close upon activation of a smoke detector.

Based on observation, the facility failed to maintain construction of smoke barriers walls in a condition to provide at least an one half hour fire resistance rating.

Findings include;

On July 6, 2010 at 7:32 a.m., during a survey of the Los Angeles campus facility, the evaluator, accompanied by the engineering project coordinator, observed a 1-inch by 1-inch penetration through a fifth floor smoke barrier wall above the nurses station.

Between 7:32 a.m. and 8:18 a.m., there was a 3-inch diameter pipe that was cut and not sealed penetrating through the smoke barrier wall in the 5th floor attic space above the cross corridor door near room 507.

At 8:18 a.m., there was a 1-inch diameter pipe that was not sealed penetrating through the smoke barrier wall in the 3rd floor attic space above the cross corridor door near room 306.


There was a penetration at a fourth floor smoke barrier wall by rooms 407 and 408, visible through the corridor attic space.

At 10:10 a.m., there was a 1 1/2-inch by 1 1/2-inch penetration at the first floor smoke barrier wall above the cross corridor door by the administrator's office, visible through the corridor attic space.

NFPA 101 Life Safety Code 2000 edition

19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel. Positive latching shall not be required

8.3.4.1 Doors in smoke barriers shall close the opening leaving only the minimal clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

Based on observation and interview the facility failed to ensure one cross-corridor smoke barrier door closed.

Finding:

On July 6, 2010 at 10:51 a.m., during a survey of the Los Angeles campus facility, the evaluator accompanied by the engineering project coordinator, observed an 1 hour fire rated cross-corridor door located near the nursing administrators office. The door failed to close upon activation of the fire alarm system, leaving a 6 inch opening along the vertical length of the door. The door was tested three times.

Based on observation and interview, the facility failed to provide an 3/4 hour fire rated construction for the Mammography Room, an hazardous area.

Finding:

Western Campus

On June 29, 2010, the evaluator conducted an inspection of the Mammography Room located on the lower level. The Mammography Room had no fire sprinklers. The evaluator examined the interior door and door frame. The door frame was 3/4 hour fire rated and the door was hollow.

The evaluator conducted an inspection of the 3rd floor and observed that the Laundry Chute Corridor door was missing the self-closing device.

The evaluator inspected the 2nd floor PACU surgery Unit suite and observed the following equipment located in the corridor, in front of a fire exit and medical gas emergency cut-off wall switch: one large Biohazard bin, 1 large trash container, and 1 large soiled linen cart.

An interview was held with the Building Supervisor and he stated that he did not know why the door was hollow and he would have the self-closing device replaced as soon as possible.

Based on observation, the facility failed to provide a stairway with protection against fire or smoke from other parts of the building.

Findings include;

On July 7, 2010 at 11:02 a.m. , during a survey of the Hawthorne campus facility, accompanied by engineering, the evaluator observed a door was missing from the door frame assembly at the top landing of an interior stairway. Closer observation revealed the stairway connected a large upstairs general storage area that was greater than 50 square feet to the first floor main lobby.

Further observation revealed the door assembly at the bottom of the stairway landing did not have a label or plate indicating the fire resistance rating of the door assembly.

Based on observation and interview, the facility failed to maintain the smoke compartment corridor and fire exit access clear of all non-essential equipment at all times.

Findings include:

Western Campus

On June 30, 2010, the evaluator conducted an inspection and survey of the facility's second floor PACU surgical suite. The evaluator observed a long two shelf cart held in the fire exit access corridor and near the set of smoke compartment fire doors. The cart was empty and not in use at the time of the survey.

An interview was held with the Building Supervisor and he stated that the shelf would be removed as soon as possible.

Based on record review, the facility failed to provide documented evidence fire drills were held at least quarterly on each shift to ensure all personnel were drilled not less than once in each 3-month period and under varying conditions. This is a repeat deficiency.

Findings:

Western Campus

On June 29, 2010, the evaluator conducted a record review of the fire drills which did not contain documented evidence of varied fire emergency situations and conditions. An interview was held with the person in charge of coordinating the fire drills and he stated that he informs the staff about the different fire emergency situations at the start of the fire drill but it is not documented. This is a repeat deficiency.


A review of the fire drill reports revealed no documented evidence that eight departments participated in the quarterly fire drills. 2 of 4 quarters in the year 2010 did not include participation from the following departments: Administration, Accounting, Medical Staff, Marketing, Central Supply, Intensive Care Unit, Case Management, and Infection Control.

Fire drills allow the staff to simulate the unusual conditions and situations occurring in case of fire and also familiarize the staff with the facility's procedures in the event of a true fire emergency.

Based on observation, the facility failed to ensure the fire alarm system provided effective warning of fire in any and all parts of the building.

Findings include;

On July 6, 2009 at 10:35 a.m., during a survey and test of the fire alarm system of the Los Angeles campus facility the evaluator accompanied by the engineering project coordinator, observed a corridor door on the first floor next to the lobby reception cubicle. Further observation revealed the door opened to an isolated area of office spaces. The area consisted of six offices, one doctor's library, one conference room and one work station. Closer observation revealed that the fire alarm was not audible in the area.

This is a repeat deficiency. On November 20, 2009 during a Life Safety Code Survey conducted pursuant a Complaint Validation Survey the facility received a deficiency for failing to ensure the fire alarm system provided effective warning of fire in any and all parts of the building.

NFPA 72, National Fire Alarm Code, 1999 Edition Table 7-3.2 6(d)(1) Batteries-Fire Alarm Systems Sealed Lead-Acid Type, Charger Test (Replace battery every 4 years.).

NFPA 101 Life Safety Code, 2000 Edition

9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

NFPA 72 National Fire Alarm Code, 1999 Edition

1-6.3 Records. A complete, unalterable record of the tests and operations of each system shall be kept until the next test and for 1 year thereafter. The record shall be available for examination and, if required, reported to the authority having jurisdiction. Archiving of records by any means shall be permitted if hard copies of the records can be provided promptly when requested.

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 observation and interview, the facility failed to ensure that the Fire Alarm Panel back up source of power, batteries, were always kept in optimal condition.

Finding:

Western Campus On June 29, 2010, the evaluator inspected the fire alarm panel located on the lower level floor. The evaluator observed that the battery alert light was lit. An interview was held with the Building Engineer and he stated, "there is no set number of years on how long battery should last." The battery was dated April 17, 2006. An interview was held with the Building Engineer and he stated that he would contact the fire alarm service company as soon as possible.

On June 30, 2010, an interview was held with the Building Engineer and he stated that the service company changed the battery and the technician said that the battery could last 4 -5 years.

The evaluator asked for documentation that the battery's charge was checked on a monthly basis. The fire alarm battery inspection and test records were not not made available at the time of the survey.

Based on observation, the facility failed to ensure a sprinkler system water supply shut off control valve was supervised to sound and display at least a local alarm when closed.

Finding:

On July 6, 2010 between 11:07 a.m. and 11:10 a.m., during a survey of the Los Angeles campus facility, accompanied by the engineering project coordinator, the evaluator observed the fire alarm service technician shut one of four outside stem & yoke valves (OS&Y) that partially controlled the water supply to the automatic fire suppression sprinkler system.

The shut OS&Y failed to sound and display a supervisory signal within the facility.

Review of the fire alarm system event history report from the central monitoring station indicated that no supervisory trouble signal was received between 11:07 a.m. and 11:10 a.m., when the OS&Y was shut.

Based on observation the facility failed to provide ashtrays of safe design where smoking was permitted.

Findings include:

On July 7, 2010 at 11:55 a.m., during a survey of the Hawthorne campus facility, accompanied by engineering, the evaluator observed the neck post of a cigarette butt receptacle at the unit 2 patio. Closer observation revealed the collection base of the receptacle was missing allowing cigarette butts to collect on the ground. Further observation revealed two aggregate ash urns. The urns had their rims broken off.

At 12:01 p.m., there were cigarette butts in the collection base of a cigarette butt receptacle at the unit 1 patio. The neck post of the receptacle was missing and the base was used to hold open the unit 1 corridor door to the patio.

NFPA 701 Standard Methods of Fire Tests for Flame Propagation of Textiles and Films 19999 Edition, Chapter 15 Reporting, 15-2.1 The composition and form of the material that was tested shall be described. The description shall include the manner in which the material in the description shall be included.

Based on observation and interview, the facility failed to ensure and provide documentation that the fourth floor dining room draperies were in compliance with the provisions of NFPA 13 and NFPA 701. This is a repeat deficiency.

Finding:

Western Campus

The evaluator conducted an inspection of the partially sprinklered facility and observed window draperies without the fire resistant information tag for the fourth floor draperies located in the Dining Room window and the Second floor window curtains located in room 208.

An interview was held with the Building Supervisor and he stated that the facility needed "more time" to address this concern.

Based on observation and interview, the facility failed to ensure that soiled linen and trash collection receptacles were held in a room protected as a hazardous area .

Finding:

Western Campus

On June 30, 2010, the evaluator inspected the 2nd floor PACU surgery Unit suite and observed the following equipment held in the corridor; one large biohazard bin, 1 large trash container, and 1 large soiled linen cart. These pieces of equipment were also located in front of a fire exit and medical gas emergency cut-off wall switch.

An interview was held with the Building Engineer and he stated that these containers would be removed as soon as possible. The evaluator did not observed the medical staff in the immediate area.

(1) NFPA 13 Installation of Sprinkler Systems 1999 Edition

5-13.8.1 Sprinklers shall be installed under exterior roofs or canopies exceeding 4ft (1.2 m) in width.

Exception: Sprinklers are permitted to be omitted where the canopy or roof is of noncombustible or limited combustible construction.

5-13.8.2 Sprinklers shall be installed under roofs or canopies over areas where combustibles are stored and handled.

Based on observation, the facility failed to ensure canopies exceeding 4 feet in width were sprinklered or constructed of noncombustible or limited combustible material.

Findings:

On July 7, 2010 at 11:55 a.m. and 12:01 a.m., during a survey of the Hawthorne campus facility accompanied by engineering the evaluator observed mesh canopies exceeding 4 feet (ft.) in width at the units 1 and 2 exterior patios.

Sprinklers were not installed under the canopies.

Closer observation revealed there was no manufacturer tag or label at the canopies indicating the canopies were constructed of noncombustible or limited combustible material. Further observation revealed the patios were also smoking areas.

During an interview, engineering stated the canopy at the unit 1 patio measured 90 ft. by 15 ft. and the canopy at the unit 2 patio measured 45 ft. by 7 ft.

During record review, and by the end of the survey, the facility failed to provide any documented evidence the canopies were constructed of non-combustible or limited combustible material.



14041

(2) NFPA 99, Health Care Facilities, 1999 Edition, section 4-3.5.2.2 (b) (2) Storage Requirements (Location, Construction, Arrangement).4-3.11.2 (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.

This Standard was not met as evidenced by:

Based on observation and interview, the facility failed to ensure that the medical gas storage room electric wall fixture was installed in a fixed location not less than 5 feet above the floor.

Findings include:

The evaluator conducted an inspection of the lower level medical gas storage room. The evaluator observed that the light switch was installed below 5 feet above the floor.

An interview was held with the Building Engineer and he stated that the electric light switch would be relocated not less than 5 feet above the floor as soon as possible.

Based on interview, the facility failed to develop an approved policy and procedure regarding the fire alarm system out of service for more than 4 hours in a 24-hour period In the event of an inoperable fire alarm system, approved policies and procedures relating to the protection of the facility, along with implementation, would help in the prevention and/or management of a fire emergency. This is a repeat deficiency

Findings include:

Western Campus

The evaluator conducted a record review of the policy and procedure regarding an interruption of the fire alarm system.

A review of the records revealed that after 10 hours the facility would implement the Fire Watch procedure and contact and notify the authority having jurisdiction. This is a repeat deficiency and the authority having jurisdiction must be contacted after four hours and not ten hours as contained in the facility's policy and procedure.

In the event of an inoperable fire alarm system, approved policies and procedures relating to the protection of the facility, along with implementation, would help in the prevention and/or management of a fire emergency.

Based on observation and interview, activation of smoke detectors at elevator lobbies of one of three elevators, that had a travel distance greater than 25 feet, failed to recall the elevator car to the designated level, and activation of the smoke detector at the elevator lobby of the designated level, failed to return the car to an alternate level.

Findings:

On July 6, 2010 at 1:33 p.m., during a test of the elevator lobby's smoke detectors for the #3 elevator at the Los Angeles campus facility, the evaluator accompanied by the engineering project coordinator, observed the fire alarm service technician activate the 5th floor service elevator lobby smoke detector. The evaluator was able to call the elevator car back up to the 5th floor and automatically open its door during the activation of the fire alarm by the 5th floor elevator lobby smoke detector.

At 1:36 p.m., the technician activated the 3rd floor service elevator lobby smoke detector. The evaluator was able to call the elevator car back up to the 3rd floor and automatically open its door during the activation of the fire alarm by the 3rd floor elevator lobby smoke detector.

At 1:37 p.m., the technician activated the first floor service elevator lobby smoke detector. The elevator car remained on the first floor and automatically opened its door during the activation of the fire alarm by the first floor elevator lobby smoke detector.

Between 1:37 p.m. and 1:52 p.m., the technician activated the lower level service elevator lobby smoke detector. The elevator car remained on the lower level and automatically opened its door during the activation of the fire alarm by the first floor elevator lobby smoke detector.

At 1:52 p.m., the technician activated the 6th floor service elevator lobby smoke detector. The elevator car remained on the 6th floor and automatically opened its door during the activation of the fire alarm by the first floor elevator lobby smoke detector.

Only the lower level, first, third, fifth, and sixth floor elevator lobby smoke detectors were tested for the #3 elevator.

On July 9, 2010, during an interview, the engineering project coordinator stated, he did not know why activation of the elevator lobby's smoke detectors failed to recall the elevator car to the designated level and remain there. He also stated the elevator car does recall to the designated level and remain there, but that when the first floor (designated level) elevator lobby smoke detector was activated the elevator car remains on the first floor or can be called to the first floor where it automatically opens its door. He further stated the elevator was not currently able to return the elevator car to an alternate level when the designated floor's elevator lobby smoke detector was activated and the controls needed to be modernized for the elevator to have full recall.

This is a repeat deficiency. On November 20, 2009, during a Life Safety Code Survey conducted pursuant a Complaint Validation Survey, the facility received a deficiency for having one of three elevators fail to recall the elevator car to the ground floor or other pre-designated floor, other than the fire floor.