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Based on observation and interview, the facility failed to ensure that hazardous use rooms were protected at all times with an one hour rated construction.

Finding:

On June 2, 2015, at 12:15 p.m., the evaluator conducted an inspection of the electrical room located on the 3rd floor, the locked unit, and the basement. The evaluator observed unsealed 3-inch openings in the ceiling. They appeared to be communication wires (white and blue). The basement electrical room had a 6-inch by 6-inch cut out of the wall over the door.

The evaluator held an interview with the Building Engineer and he stated that all the unsealed openings shall be properly sealed as soon as possible.

This affected the exit access corridors located on the 3rd floor locked unit and in the basement.

NFPA 1600, 2000 Edition, 2-2 Program Coordinator. The program coordinator shall be appointed by the entity and shall be authorized to administer and keep current the program in consultation with the Disaster/Emergency Management Program Committee.
2-3 Program Committee. 2-3.1 The program committee shall be established by the entity in accordance with is policy.
2-3.2 The committee shall include the program coordinator and others who have the appropriate expertise and knowledge of the entity and the authority to commit resources from all key functional areas within the entity and shall solicit applicable external representation from public and private entities.
Based on interview and record review, the facility failed to develop a Disaster/Emergency Policy and Procedure in regards to a disaster committee comprised of experts with the knowledge and the ability to function and act effectively, develop impact analysis based on consensus of expert opinions, identify shortfalls, and determine a need for mutual aid.

Finding:

On June 2, 2015, at 12:55 p.m., the evaluator conducted a review of the facility's emergency and disaster plan. The evaluator noted the disaster committee did not include the public, private sector, and nongovernmental organizations that are experts in the area of emergency disaster preparedness.

At 1:15 p.m., the evaluator interviewed staff II, in charge of the disaster plan committee and she stated that the committee is comprised of only the facility's staff.

The disaster / emergency plan shall include qualified emergency and disaster public and private emergency agencies or organizations in the facility's disaster preparedness plan per NFPA.

Based on observation, record review, and interview the facility failed to ensure that the fire sprinkler system test, service, and maintenance records were always available to the Authority having Jurisdiction.

Finding:

On June 4, 2015, at 9:00 a.m., the evaluator conducted an interview with the Building Supervisor. The evaluator request the fire sprinkler test, service, and maintenance record. The Building Supervisor stated that the fire sprinkler annual test is not available at the time of the survey.

The fire sprinkler test, service, and maintenance records shall be made available to the Authority having Jurisdiction at all times.

(1) Annual Sprinkler Service, NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems

1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include but are not limited to, valve inspections; flow, drain, and pump tests; and trip test of dry pipe, deluge, and preaction valves

Based on record review and interview, the facility failed to ensure annual service records of the automatic sprinkler system were available at the time of the recertification survey. The service records must include routine inspections, tests, and maintenance of the automatic sprinkler system in the event of a fire emergency.

Finding:

On June 4, 2015, the evaluator conducted a review of the Life Safety Code service and maintenance record. The evaluator observed that no current fire sprinkler record was available and the last time the fire sprinklers were fully serviced was on March 25, 2013.

The evaluator held an interview with the Building Engineer and he stated that he would contact the service company regarding the documentation as soon as possible.

The deficiency affected a three story building, two elevators, and a basement.

(2) NFPA 110 Standard for Emergency and Standby Power Systems 99 Ed 6-3.5, Transfer switches shall be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion removal dust and dirt, and replacement of contacts when required.

Based on observation and record review, the facility failed to provide evidence that the emergency back-up generator's transfer was tested and subjected to a maintenance program.

Finding:

On June 4, 2015, at 2:00 p.m., the evaluator conducted a review of the generator's service and maintenance records. The evaluator reviewed the documents and did not see any service or maintenance record regarding the generator's automatic transfer switch ATS).
An ATS is a critical part of any emergency power supply system (EPSS). ATS are installed in the emergency power system to transfer the electrical load from the normal power source to the emergency power source upon failure of normal power. Maintenance programs for transfer switches include checking of connections, inspection or testing for evidence of overheating and excessive contacts when required, removal of dust and dirt, and replacement of contacts when necessary based on the manufacturer's recommendation.
The evaluator conducted an interview with the Building Engineer and he stated that the ATS is activated and tested at the time of the generator test but there was no record of the annual service and maintenance.
(3) NFPA 101, 2000 Edition, 7.10.8.1 No Exit. Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows: NO EXIT. Such sign shall have the word NO in letters 2 inches high with a stroke width of 3/8 inches and the word EXIT in letters 1 inch high, with the word EXIT below the NO.
Based on observation and record review, the facility failed to ensure that stairway leading to the roof was clearly identified as NOT an exit in case of emergency and/or evacuation situation.
Finding:
On June 2, 2015, at 11:30 a.m., the evaluator conducted an inspection of the facility's 3rd floor. The evaluator observed a fire exit access stairway with no exit sign(s) in the area directing the occupants out of the building in case of a fire or evacuation emergency.
The evaluator conducted an interview with the Building Supervisor and he stated that the staff and occupants are to exit going down the stairs. He also stated that there is no roof exiting and that the door was locked at the top of the stairs leading to the roof.
In case of a fire or evacuation emergency, the exit access stairway shall be clearly identified as to the exit or the NO EXIT direction at all times.

NFPA 99, Chapter 3, Electrical System, 3-4.4.1.1, Maintenance and Testing of Alternate Power Source and Transfer Switches (b) 3 Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are need to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. ..... The Occupational Safety and Health Administration (OSHA) mandates training in such areas as electrical safety, personal protective equipment, and hazard communication. Relevance to emergency generators should be determined.

NFPA 110 Standard for Emergency and Standby Power Systems 99 Ed
6-3.4, A written record of the EPSS (Emergency Power Supply System) 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
6-3.5 Transfer switches shall be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contract erosion, removal of dust and dirt, and replacement of of contacts when required.
6-3.6 Storage batteries, including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer's specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects.
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.
6-4.1 Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. The date and time of day for required testing shall be decided by the owner, based on facility operations.
6-4.2.2 Diesel-powered EPS (Emergency Power Supply) installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Based on observation, interview, and record review, the facility failed to provide documentation and ensure that the emergency back up source of power, the generator and its' components, were serviced and maintained as often as required for a Type 2, 3-story, mental health facility with a basement and two elevators.

Finding:

On June 2 and 4, 2015, the evaluator conducted an inspection of the Life Safety Code system. The facility has a generator located in the back of the facility.

On June 4, 2015, the evaluator held an interview with the Building Engineer and a request for the generator's service and maintenance records. The Building Engineer stated that he tested the generator under load every week. A review of the generator weekly load test did reflect the following: battery specific gravity/electrolyte level (not just the fluid level), coolant level, the operating temperature, the generator's nameplate rating and the amount of load kW.

In case of a loss of normal power, the facility shall ensure and provide documented evidence that the generator and all its' components are tested, serviced, and maintained in optimal condition at all times.

NFPA 70, NEC 1999, 7-5.2.2.1 Patient Care Area. Power leakage, The leakage current for facility-owned appliances (e.g., housekeeping or maintenance appliances) that are used in patient care vicinity and are likely to contact the patient shall be measured. The leakage current shall be less than 500 microampere. This shall be made with Switch A in Figure 7-5.1.3.5 in the open position for two -wire equipment that is not double-insulated.
7-5.1.3.1 Physical Integrity. The physical integrity of the power cord and attachment plug and cord-strain relief shall be confirmed by visual inspection or other appropriate test.
7-5.1.3.5 Chassis Leakage Current, Portable Equipment (a) The leakage current for cord-connected appliances shall be measured. The limit shall be 300 microampere. Figure 7-5.1.3.5 shows one method of performing this test. If multiple devices are connected together and one power cord supplies power, the leakage current shall be measured as an assembly.
When multiple devices are connected together and more than one power cord supplies power, the devices shall be separated into groups according to their power supply cord and the leakage current shall be measured independently for each group as an assembly.

Based on observation and interview, the facility failed to ensure that all facility owned and patient related electrical equipment were checked for safety and physical integrity at all times.

Finding:

On June 4, 2015, at 11:00 a.m., the evaluator conducted an inspection of the facility and observed medication refrigerators, computers, and printers throughout the facility.

The evaluator held an interview with the Building Engineer and he stated that he visually checks the equipment but he had no documentation or policy and procedure regarding voltage leakage on these electrical items.

In case of an electrical leakage, the facility shall develop and implement a policy and procedure to ensure that all electrical patient care and staff equipment are in good repair at all times.

Based on observation and interview, the facility failed to develop a policy and procedure regarding an out of service or inoperable fire sprinkler system.

Finding:

On June 2, 2015, the evaluator conducted a Life Safety Code inspection of the facility.

The evaluator requested the policy and procedure in case the fire sprinkler system was out of service for more than 4 hours in a 24 hour period.

An interview was held with a Building Staff member and he stated that there was no policy and procedure at the time of the survey.

In case of an out of service or inoperable fire sprinkler system, the policy and procedure shall stipulate that the facility would contact the authority having jurisdiction, and the building should be evacuated and/or an approved fire watch shall be implemented.