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The facility failed to ensure a complete two-hour fire resistive rated wall assembly between the Richard P Stadter Psychiatric Center and the hospital.

Observation determined:

1) The two-hour barrier had holes that were not sealed with fire-rated material.

2) The head-of-wall joint was not constructed to meet the requirements of a two-hour fire resistive rated wall assembly. Electrical conduit was run parallel with the head-of-wall joint and was fire caulked as being part of the head-of-wall joint.

3) The three 90-minute fire rated doors in the two-hour fire separation wall did not latch into the door frames and the doors were not equipped with fire-rated smoke gaskets or intumescent fire gaskets.

4) There was a lack of documentation for the fire-rating of the control joints installed above the three 90-minute fire-rated doors.

The facility failed to ensure wall covering in exit systems had a Class A or B interior finish rating.

Due to the lack interior finish documentation, it could not be determined if the wood wainscot used to cover the lower part of the corridor walls had an interior wall finish rating of at least Class A or B.

When applying exception No. 1 to 19.3.6.1 for areas open to the corridor of unlimited size, the space must be protected by an electrically supervised automatic smoke detection system when the space is not in direct supervision of the facility staff from a nurses station or similar space.

The facility failed to ensure areas that were open to the corridor were electrically supervised with an automatic smoke detection system or in direct supervision of a nurses station.

Observation determined:

The Unit B - Blue Section had a high-ceiling common area that was open to the corridor and was not protected by the facility's electrically supervised automatic smoke detection system.

The smoke barriers in the original 1999 building must be at least one-half hour fire resistant and smoke resistant. The smoke barriers between the 1999 building and the 2008 building must be at least two-hour fire resistant smoke resistant to maintain horizontal exits required for acceptable exiting. The smoke barrier in the 2008 building must be at least one-hour fire resistant and smoke resistant.

1) The facility failed to ensure three (3) of three (3) smoke barriers in the existing 1999 building were at least one-half hour fire resistant and smoke resistant.

Observation determined low-voltage wiring penetrations in the three (3) smoke barriers were not sealed with fire rated material.

2) The facility failed to ensure three (3) of three (3) fire/smoke barriers between the 1999 building and the 2008 building were at least two-hour fire resistant and smoke resistant.

Observation determined:

a) Low-voltage wiring penetrations in the three (3) smoke barriers were not sealed with fire rated material.

b) The edges of the gypsum board at the south smoke barrier wall were not sealed with fire rated material as required for a two-hour fire separation.

c) The seams of the gypsum board at the north smoke barrier wall had large gaps and were not sealed with fire rated material as required for a two-hour fire separation.

d) The auxiliary fire latch and the astragal were not installed on the 90-minute fire door in the south two-hour smoke barrier.

3) The facility failed to ensure one (1) of one (1) smoke barrier in the 2008 building was at least one-hour fire resistant and smoke resistant.

Observation determined the low-voltage wiring and pipe penetrations in the one (1) smoke barrier installed in the 2008 building were not sealed with fire-rated material that would meet the one-hour fire resistant and smoke resistive rating of the wall.

Exits must terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge must be of required width and size to provide all occupants with safe access to a public way. 7.7.1

To ensure adequate exit capability, CMS requires asphalt or concrete surfaces from exterior exits to public ways.

Observation determined the Unit B north exterior exit discharge traversed the lawn to get to a public way.

The emergency illumination lighting system must be arranged to provide the required illumination automatically. 7.9.2.2

Note: CMS allows a light fixture equipped with a single long-life bulb with a quick strike feature to illuminate exit discharge.

The facility failed to ensure the illumination of means of egress, including exit discharge, was arranged so that failure of a single lighting fixture (bulb) would not leave the area in darkness. There are several types and styles of exterior light fixtures located at the various exterior exits around the building.

Observation determined that eight (8) of the eleven (11) exterior exits were illuminated with light fixtures with a single high pressure sodium bulb without quick strike capabilities, single high pressure sodium bulb without the secondary incandescent bulb, or single incandescent bulb.

Exits must be marked by approved signage that is readily visible from any direction of exit access and that obviously and clearly identifies the exit. 7.10.1.2 It appears that the architect designed the building with exiting provisions for a suite of rooms in different areas of the building. If suites are used, the suites must be in compliance with the 2000 Life Safety Code and the exit signage must be installed so as not to direct a person to exit into a suite of rooms.

The facility failed to mark exit paths with readily visible signage that clearly identify the path of exit.

Observation determined the exit paths throughout the facility were not marked by approved signage to clearly identified the path of exit. Exit signage directed individuals to enter a suite of rooms that were not accessible to the general public and to exit through service corridors that were not at least six (6) feet in width.

The administration of health care facilities is to develop and distribute to all supervisory personnel written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees are to be periodically instructed and kept informed with respect to their duties under the plan.

Review of policies/procedures indicated the facility failed to provide a written evacuation plan that clearly indicates safe areas of refuge in the event of a fire. All cross-corridor doors were not located at complying smoke barriers and the evacuation plan did not identify each smoke compartment.

The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with the manufacturer's specifications and is in compliance with NFPA 72.

1) Review of the fire alarm test records indicated the facility failed to document the monthly testing of fire alarm system during July 2010.

2) Observation determined the connecting link corridor to the hospital was not equipped with smoke detectors that were a part of the smoke detection system that was installed throughout the Richard P Stadter Psychiatric Center.

Visual inspection frequencies and specific testing and maintenance frequencies for smoke detection systems are dictated by the prescriptive requirements of NFPA 72, National Fire Alarm Code (Chapter 10-Inspection, Testing and Maintenance Tables 10.3.1, 10.4.2.2 and 10.4.3). This code identifies specific inspection, testing and maintenance frequencies and methods.

Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years.

The facility failed to ensure smoke detectors were maintained, inspected and tested in accordance with the manufacturer's specifications.

Review of the fire alarm test results indicated the smoke detection system did not have sensitivity testing at frequencies in compliance with the minimum requirements of NFPA 72. The test records indicated the smoke detectors have not been tested for sensitivity since 2006. The 2006 smoke detector sensitivity test was the only test on file and the smoke detectors that were added during 2008 addition were not sensitivity tested during the first year in operation.

Automatic fire sprinkler systems must be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

The facility did not install the automatic sprinkler system in accordance with NFPA 13 to provide adequate coverage for all portions of the building.

Observation determined:

1) The connecting link corridor to the hospital is part of Richard P Stadter Psychiatric Center but the sprinkler system was not connected to the Richard P Stadter Psychiatric Center automatic sprinkler system.

2) Ordinary temperature rated sprinklers must be used throughout buildings. The sprinklers in the Mechanical/Electrical Room 343 were not ordinary rated, but were intermediate temperature rated. The sprinklers were green color coded which is an indication of an intermediate temperature rating. These sprinklers are to be used only when the maximum ceiling temperature exceeds 150 deg Fahrenheit. The contents of this room did not warrant treatment as ordinary or extra hazard occupancy. No fuel-fired equipment was located in this area.

Review of documentation determined the facility failed to ensure that loosely hanging fabrics were flame resistant. The facility failed to provide flame resistant documentation for drapes and cubicle curtains that were hung throughout the facility.

Free-standing oxygen cylinders must be properly chained or supported in a proper cylinder stand or cart. NFPA 99 9.7.2.3

The facility failed to secure all oxygen cylinders in the Oxygen Storage Room. Observation determined four free-standing oxygen cylinders in the Oxygen Storage Room were not chained or supported.

1) Transfer switches must be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required. NFPA 110, Standard for Emergency and Standby Power Systems.

Based on record review, the facility failed to provide evidence of quarterly checks and maintenance of the emergency generator electrical transfer switch.

2) NFPA 241 Section 8.6.2 Temporary Separation Walls.
a) Protection shall be provided to separate an occupied portion of the structure from a portion of the structure undergoing alteration, construction, or demolition operations when such operations are considered as having a higher level of hazard than the occupied portion of the building.
b) Walls shall have at least a 1-hour fire resistance rating.
c) Opening protection shall have at least a 45-minute fire protection rating.

The facility failed to provide fire rated partitions between the occupied spaces and the construction areas.

Observation determined that one-hour fire rated partitions were not provided between the new construction areas and the occupied portions of the facility.

3) Records review indicated the facility failed to maintain fire dampers in a reliable operating condition as required by NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. Maintenance of fire dampers is required at least every 4 years. Maintenance of fire dampers includes:

(a) Fusible links shall be removed.
(b) All dampers shall be operated to verify that they close fully.
(c) The latch, if provided, shall be checked.
(d) Moving parts shall be lubricated as necessary.

4) Foam plastic insulation and components shall be separated from the interior of a building and from plenums by an approved thermal barrier of ? in. (13 mm) gypsum wallboard or equivalent material that will limit the average temperature rise of the unexposed surface to not more than 250?F (121?C) after 15 minutes of fire exposure complying with the standard time-temperature curve of NFPA 251, Standard Methods of Tests of Fire Resistance of Building Construction and Materials. NFPA 5000, Building Construction and Safety Code, Section 48.3.3.1

The facility failed to enclose the exterior foam plastic insulation with a thermal barrier. The exterior foam plastic insulation was not removed or enclosed with a thermal barrier when the hospital was attached to the south side of the Richard P Stadter Psychiatric Center.

The facility failed to inspect the generator on a weekly basis and exercise the emergency generator under load for 30 minutes monthly.

Generator test records did not verify the generator was inspected weekly and was monthly exercised under load for 30 minutes.