HospitalInspections.org

Based on observations the facility failed to ensure that the horizontal exit between the hospital and the skilled nursing center is in compliance with Chapter 7 sections 7.2.4.3 and 7.2.4.3.5 of the 2012 edition of the Life Safety Code.
-Section 7.2.4.3 states fire barriers separating buildings or areas between which there are horizontal exits shall have a minimum 2-hour fire resistance rating, unless otherwise provided in 7.2.4.4.1, and shall provide a separation that is continuous to the finished
ground level. (See also Section 8.3.)
-Section 7.2.4.3.5 states fire barriers forming horizontal exits shall not be penetrated by ducts, unless one of the following criteria is met:
(1) The ducts are existing penetrations protected by approved and listed fire dampers.
(2) The building is protected throughout by an approved,supervised automatic sprinkler system in accordance with
Section 9.7.

Findings Include:

While conducting the facility tour during the morning and afternoon hours of 2/15/17 observations revealed the following.
1. There is an approximate four (4) inch round hole located above the suspended ceiling in the two hour fire resistive barrier above the cross corridor doors of the horizontal exit leading from the hospital into the skilled nursing facility.
2. There is a two (2) foot by one (1) foot HVAC duct penetrating the two hour fire resistive barrier above the cross corridor doors of the horizontal exit leading from the hospital into the skilled nursing facility. The ductwork is not sealed tight to the gypsum wall board leaving voids between the two surfaces.
3. There is a two (2) foot by one (1) foot non dampered HVAC duct penetrating the two hour fire resistive barrier above the suspended ceiling. The noncompliant ductwork is located in the portion of the horizontal exit barrier corridor that abuts the rehab gym of the skilled nursing facility. The ductwork is required to be a equipped with a fire damper listed for a two hour fire separation.
4. There is a sprinkler pipe penetrating the two hour fire resistive horizontal exit barrier above the suspended ceiling of the Eleanor Blum Library. The sprinkler pipe is not tightly sealed to the gypsum wallboard leaving voids between the two surfaces.

As a result of the finding the facility is found to be non-compliant with Chapter 7 sections 7.2.4.3 and 7.2.4.3.5 of the 2012 edition of the Life Safety Code.

The findings were confirmed by facility maintenance personnel and the facility Administrator during the exit conference.

Based on observations the facility failed to ensure that corridor widths are maintained as required. Section 19.2.3.4 states, any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by one of the following:

(5)Where the corridor width is at least 8 ft (2440 mm), projections into the required width shall be permitted for fixed furniture, provided that all of the following conditions are met:
(a) The fixed furniture is securely attached to the floor or to the wall.
(b) The fixed furniture does not reduce the clear unobstructed corridor width to less than 6 ft (1830 mm), except as permitted by 19.2.3.4(2).
(c) The fixed furniture is located only on one side of the corridor.
(d) The fixed furniture is grouped such that each grouping does not exceed an area of 50 ft 2 (4.6 m2).
(e) The fixed furniture groupings addressed in 19.2.3.4(5)(d) are separated from each other by a distance of at least 10 ft (3050 mm).
(f)The fixed furniture is located so as to not obstruct access to building service and fire protection equipment.
(g) Corridors throughout the smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the fixed furniture spaces are arranged and located to allow direct supervision by the facility staff from a
nurses' station or similar space.
(h) The smoke compartment is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.8.

FINDINGS INCLUDE:

Observations while touring the Berenson Building on 2/14/17 and 2/15/17 revealed that numerous chairs were being used in the corridors on the 5th, 4th, 3rd, 2nd, and 1st floors. The chairs were not affixed to the walls or the floors per (5)(a). In addition, the Berenson Building is not provided with a complete automatic sprinkler system per (5)(h).

The findings were confirmed by facility maintenance personnel and the facility Administrator during the exit conference.

Based on observations, the facility failed to ensure that hazardous areas are enclosed as required.

Section 19.3.2.1 states 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.

Section 19.3.2.1.2 states 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.

FINDINGS INCLUDE:

Observations during a tour of the facility on the afternoon of 2/16/17 revealed one leaf of the zero level corridor door to the waste disposal chute room, identified as door J0717, did not properly close and latch in it's frame due to a missing door handle.

As a result of the deficiency, the facility failed to maintain compliance with section 19.3.2.1.2

The findings were confirmed by facility maintenance personnel and the facility Administrator during the exit conference.

Based on observations and confirmed by staff interview the facility failed to ensure compliancy with Chapter 19 of the 2012 edition of NFPA 101 "Life Safety Code". Chapter 19 "Existing Health Care Occupancies" Section 19.3.2.5.1 states cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.5.4.

Chapter 19 Section 19.3.2.5.3 states that within a smoke compartment, where residential or commercial cooking equipment is used to prepare meals for 30 or fewer persons, one cooking facility shall be permitted to be open to the corridor, provided that specific conditions are met. Condition (8) states portable fire extinguishers in accordance with NFPA 96 are located in all kitchen areas. Condition (10) states procedures for the use, inspection, testing, and maintenance of the cooking equipment are in accordance with Chapter 11 of NFPA 96 and the manufacturer ' s instructions and are followed.

Section 9.2.3 states commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 96 Section 11.2.1 states maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having at least every 6 months.

-11.2.2 All actuation and control components, including remote manual pull stations, mechanical and electrical devices, detectors, and actuators, shall be tested for proper operation during the inspection in accordance with the manufacturer ' s procedures.

-11.2.3 The specific inspection and maintenance requirements of the extinguishing system standards as well as the applicable installation and maintenance manuals for the listed system and service bulletins shall be followed.

-11.2.4 Fusible links of the metal alloy type and automatic sprinklers of the metal alloy type shall be replaced at least semiannually except as permitted by 11.2.6 and 11.2.7.

-11.2.5 The year of manufacture and the date of installation of the fusible links shall be marked on the system inspection tag.

NFPA 96, Chapter 2 states NFPA 17A Standard for Wet Chemical Extinguishing Systems, 2009 edition or portions thereof are referenced within NFPA 96 and shall be considered part of the requirements of this document.

NFPA 17A, Section 7.2.1 stases on a monthly basis, inspection shall be conducted in
accordance with the manufacturer's listed installation and maintenance manual or the owner's manual.

-Section 7.2.2 At a minimum, this "quick check" or inspection shall include verification of the following:
(1) The extinguishing system is in its proper location.
(2) The manual actuators are unobstructed.
(3) The tamper indicators and seals are intact.
(4) The maintenance tag or certificate is in place.
(5) No obvious physical damage or condition exists that might prevent operation.
(6) The pressure gauge(s), if provided, shall be inspected physically or electronically to ensure it is in the operable
range.
(7) The nozzle blowoff caps, where provided, are intact and undamaged.
(8) Neither the protected equipment nor the hazard has not been replaced, modified, or relocated.

-Section 7.2.3 If any deficiencies are found, appropriate corrective action shall be taken immediately.

-Section 7.2.3.1 Where the corrective action involves maintenance, it shall be conducted by a service technician as outlined in 7.3.1.

-Section 7.2.4 Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions.

-Section 7.2.5 At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded.

-Section 7.2.6 The records shall be retained for the period between the semiannual maintenance inspections.

NFPA 96, 10.10.1 states portable fire extinguishers shall be installed in kitchen cooking areas in accordance with NFPA 10 and shall be specifically listed for such use.

10.10.2 Portable extinguishers shall use agents that saponify upon contact with hot grease in accordance with NFPA 10 (Class K extinguishers).

Findings Include:

1. While conducting a facility tour during 2/14/17 observations revealed the facility has 15 household units. Each of the households contains residential cooking facilities located within a smoke compartment that is open to the corridor and used for the preparation of meals for a population of less than thirty (30) persons. A check of the required conditions included in Section 19.3.2.5.3 revealed the following:

a. Documentation was not available to substantiate the required semi-annual maintenance inspections of the extinguishment systems were conducted in accordance with NFPA 96 Section 11.2.1.

b. The facility failed to maintain the required fire suppression system on the 3rd floor North East household in accordance with NFPA 96 as the pressure gauge indicated the cylinder was in the "recharge" position.

2. While conducting an inspection of the facility on the afternoon of 2/15/17, it was observed that the inspection tags affixed to the manual actuators of both fire suppression systems in the main kitchen were not being initialed in acknowledgment of the performance of a required monthly inspection as required by NFPA 17A, Section 7.2.1

3. While conducting an inspection of the facility on the afternoon of 2/16/17 it was revealed that the extinguishers in the household kitchen areas do not have a K classification as required by NFPA 96, section 10.10.2.

As a result of the findings, the facility is found to be non-compliant with NFPA 101, NFPA 96, and NFPA 17A.

The findings were confirmed by facility maintenance personnel and the facility Administrator during the exit conference.

Based on observations the facility failed to ensure compliancy with the 2010 edition of NFPA 13 Standard for the Installations of Sprinkler Systems.

-Section 4.1 Level of Protection states a building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas except where specific sections of this standard permit the omission of sprinklers.

-Section 8.15.3.2.1 states in noncombustible stair shafts having noncombustible stairs with noncombustible or limited-combustible finishes, sprinklers shall be installed at the top of the shaft and under the first accessible landing above the bottom of the shaft.

Findings Include:

While conducting the facility tour during the morning and afternoon hours of 2/14/17 observations revealed the following:

1. The top (roof access) level of the J7 stairway is not equipped with sprinkler protection.
2. The roof access stairway located in the service elevator lobby is not equipped with sprinkler protection.
3. The storage closet located on the third floor Core in the Clinical area is not equipped with sprinkler protection.
4. The walk-in freezer, identified as the "healthcare freezer", located in the facility's main kitchen is not equipped with sprinkler protection.
Note: NFPA Formal Interpretation 78-6 states that walk-in type freezers/coolers require sprinklers because they are part of the premises.

The findings were confirmed by facility maintenance personnel and the facility Administrator during the exit conference.

Based on observations and confirmed by staff the facility failed to ensure compliance with Chapter 19. Section 19.3.6.3.1 states doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:
(1) 1-3/4 in. (44 mm) thick, solid-bonded core wood
(2) Material that resists fire for a minimum of 20 minutes

Section 19.3.6.3.2 states that the requirements of 19.3.6.3.1 shall not apply where otherwise permitted by either of the following:
(1)Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials shall not be required to comply with 19.3.6.3.1.
(2) In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, the door construction materials requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.

Findings Include:

On 2/15/17 it was noted that the corridor door to the IT Room on the zero level was equipped with a 22" x 22" louver. Therefore, the door was not smoke tight in accordance with Section 19.3.6.3.1.

The findings were confirmed by facility maintenance personnel and the facility Administrator during the exit conference.

Based on observation, the facility failed to ensure compliance with Section 19.3.7.3 which states any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following:
(1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c).
(b) Not less than two separate smoke compartments shall be provided on each floor.
(2)Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating,
and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with
19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.

Section 19.3.7.6 states openings in smoke barriers shall be protected using one of the following methods:
(1) Fire-rated glazing
(2) Wired glass panels in steel frames
(3) Doors, such as 13.4 in. (44 mm) thick, solid-bonded woodcore doors
(4) Construction that resists fire for a minimum of 20 minutes.

Section 8.5.6.2 states penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.

THE FINDINGS INCLUDE:

1. Observations while touring the facility on 2/15/17 revealed smoke barrier walls had voids located above the suspended ceilings around pipes and wires as indicated but not limited to:

3 South
- a void around the copper pipe which penetrates the smoke barrier wall that leads from the soiled utility room to the household
- voids around a wire and a 2" cast iron pipe which penetrate the smoke barrier wall from the laundry room to the service elevator area
- voids around four cables which penetrate the smoke barrier wall above the smoke barrier door by room 7359
- voids around four pipes/conduit penetrations in the smoke barrier wall between the sitting area to the Magnolia household

2 South
- 3" x 4" void around the low voltage wiring that penetrates the smoke barrier wall from the 2nd floor gathering room to the Pine household.
- A 12" x 12" void and three voids, less than one inch diameter, in the smoke barrier wall between the laundry room and the 2 South household
- voids around a cast iron pipe and a cable where they penetrate the smoke barrier wall in the soiled utility room to 2 SW, Dogwood household.
- a 12" x 12" void in the smoke barrier wall between the storage alcove and the 2 SW household

Zero level
- voids around one conduit which penetrates the smoke barrier wall from the loading dock office to the human resources office.

2. Observations while touring the facility on 2/15/17 revealed the following ducts, but not limited to the following ducts, penetrated the zero level smoke barrier wall and were not equipped with smoke dampers: one 12' x 12", two 8" x 8", one 18" x 30 ", and two 8" round ducts. In addition, there was one 12" x 24" supply duct which penetrated the smoke barrier wall from the shell space to the corridor which was not equipped with a smoke damper.

3. The cross corridor smoke barrier wall located next to the smoke barrier doors on the zero level by the Outpatient Clinic and the Pharmacy, was equipped with two ~35" x 38" tempered vision panels. As a result, the smoke barrier wall was not protected in accordance with Section 19.3.7.6.

As a result, the facility's smoke barriers were not maintained to resist the movement of smoke in accordance with Section 19.3.7.3.

The findings were confirmed by facility maintenance personnel and the facility Administrator during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that fire drills are conducted quarterly on each shift utilizing various times and conditions.

THE FINDINGS INCLUDE:

During the morning hours of 2/15/17 while performing the record review process, it was observed that the fire drills are not conducted as required. The fire drills for the 1st shift (7:00 A.M.- 3:00 P.M.) and 2nd shift (3:00 P.M.- 11:00 P.M.) are documented as occurring at the following times:

1st Shift: 1/6/17 @ 9:55 A.M.; 10/4/16 @ 9:05 A.M.; 7/27/16 @ 10:03 A.M.; 4/4/16 @ 9:55 A.M.; and 1/21/16 @ 10:15 A.M.

2nd Shift: 2/1/17 @ 3:55 P.M.; 11/21/16 @ 3:50 P.M.; 8/22/16 @ 3:31 P.M.; 5/24/16 @ 3:53 P.M.; and 2/16/16 @ 3:49 P.M.

The following deficiencies were noted after reviewing the fire drills:

1) The fire drills conducted on the 1st Shift were not held at varying times and conditions as required. All of the drills were performed between 9:05 A.M. and 10:15 A.M.

2) The fire drills conducted on the 2nd Shift were not held at varying times and conditions as required. All of the drills were performed between 3:31 P.M. and 3:55 P.M.

As a result of the performed drills, the facility failed to comply with section 19.7.1.4.

The findings were confirmed by facility maintenance personnel and the facility Administrator during the exit conference.

Based on observations and confirmed by staff the facility failed to ensure compliance with Chapter 19 Section 19.7.8 of the 2012 edition of NFPA 101 Life Safety Code.

Section 19.7.8 Portable Space Heating Devices states the following that portable space heating-devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:
(1) Such devices are used only in non-sleeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212 degrees F (100 degrees C).

Findings Include:

While conducting the facility tour during the afternoon hours of 2/14/17 observations revealed the presence of two (2) portable electric space heaters, with heating elements capable of exceeding 212 degrees F (100 degrees C), located in the administrative office area of the Outpatient Clinic Department.

As a result of the finding the facility is found to be non-compliant with Chapter 19 Section 19.7.8.

The findings were confirmed by facility maintenance personnel and the facility Administrator during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that receptacle testing is performed as required.

Section 19.1.1.1.3 states the provisions of Chapter 4, General, shall apply.

Section 4.6.12.1 states whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.

NFPA 99 section 1.1.4.1 states chapter 6 covers the performance, maintenance, and testing of electrical systems (both normal and essential) in health care facilities.

Section 6.3.3.2.1 states the physical integrity of each receptacle shall be confirmed by visual inspection.

Section 6.3.3.2.2 states the continuity of the grounding circuit in each electrical receptacle shall be verified.

Section 6.3.3.2.3 states correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.

Section 6.3.3.2.4 states the retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

Section 6.3.4.1.1 states where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.

Section 6.3.4.1.2 states additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.

Section 6.3.4.1.3 states receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.

THE FINDINGS INCLUDE:

During the morning hours of 2/15/17 while performing the record review process, it was observed that the required receptacle testing is not performed. In addition, it was stated by maintenance staff that no receptacle testing of any kind is currently being performed.

As a result, the facility failed to comply with NFPA 99 section 6.3.4.

The findings were confirmed by facility maintenance personnel and the facility Administrator during the exit conference.