| Source: PA Building Inspection Pennsylvania Department of Health BRADFORD REGIONAL MEDICAL CENTER Building Inspection Results  |
| BRADFORD REGIONAL MEDICAL CENTER Building Inspection Results For: There are 49 surveys for this facility. Please select a date to view the survey results. 08/16/2022 10/08/2020 09/04/2019 -ACCREDITATION (TJC) 01/02/2019 09/25/2018 -ACCREDITATION (TJC) 05/16/2017 05/16/2017 05/16/2017 09/15/2016 09/15/2016 09/04/2015 -ACCREDITATION (TJC) 03/11/2015 03/11/2015 09/04/2014 07/30/2013 06/26/2013 06/26/2013 11/29/2012 11/29/2012 09/12/2012 09/12/2012 03/20/2012 03/13/2012 12/22/2010 11/18/2010 11/09/2010 09/02/2010 08/12/2010 07/20/2010 09/02/2009 04/30/2009 04/30/2009 03/13/2009 02/19/2009 11/25/2008 08/26/2008 08/26/2008 08/08/2008 08/08/2008 06/11/2008 05/07/2008 02/08/2008 11/15/2007 03/01/2007 02/22/2007 01/10/2007 12/07/2006 10/18/2006 06/28/2006 Surveys don’t appear on this website until at least 41 days have elapsed since the exit date of the survey. Initial Comments: Name – MAIN BUILDING Component – 01 Facility ID #541201 Component 01 Main Building Based on a Relicensure Survey completed on August 15-16, 2022, it was determined that Bradford Regional Medical Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. This is a six-story, Type I (322), fire resistive building, which is partially sprinklered. Plan of Correction: NFPA 101 STANDARD Building Rehabilitation Name – MAIN BUILDING Component – 01 Building Rehabilitation Repair, Renovation, Modification, or Reconstruction Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following: * Requirements of Chapter 18 and 19 * Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6 18.1.1.4.3, 19.1.1.4.3, 43.1.2.1 Change of Use or Change of Occupancy Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2 18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7) Additions Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a 2-hour fire resistance rating constructed of materials as required for the addition. Communicating openings occur only in corridors and are protected by approved self-closing fire doors with at least a 1-1/2-hour fire resistance rating. Additions comply with the requirements of Section 43.8. 18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3, 19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3, 43.1.2.3(43.8) Observations: Based on observation and interview, it was determined that the facility failed to follow building rehabilitation requirements on two of six floors. Findings include: 1. Observation on August 16, 2022, between 8:37 a.m. and 10:01 a.m., revealed the following areas were converted into storage locations without meeting hazardous area requirements. Storage items included Christmas trees, books, paperwork, bedding, and other combustible materials. The facility changed the use of these areas without the approval of State Plan Review and a granted occupancy from the Division of Life Safety: A. (8:37 a.m.) Fifth floor, resource room; B. (9:27 a.m.) Fourth floor, consultation room; C. (9:48 a.m.) Fourth floor, private sleep areas A and B; D. (10:01 a.m.) Fourth floor, patient room 498; E. (10:01 a.m.) Fourth floor, patient room 497. Interview with the director of plant services and the manager of plant services on August 16, 2022, at 10:01 a.m., confirmed the above rooms failed to meet hazardous area requirements and there were no plans approved for the unit changes. Plan of Correction:All combustible materials will be removed from the following areas by 9.9.2022: A. Fifth floor resource room. B. Fourth floor consultation room C. Fourth floor private sleep areas A and B D. Fourth floor patient room 498 E. Fourth floor patient room 497 Review of these areas during monthly rounds will be completed to ensure that these areas are not being used to store flammable items. To ensure compliance, the results of monthly rounding of these areas will be reported out at the safety Committee meetings, and any noncompliance will immediately be addressed by the manager of plant services. NFPA 101 STANDARD Multiple Occupancies – Construction Type Name – MAIN BUILDING Component – 01 Multiple Occupancies – Construction Type Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows: * The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1 * The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters. 18.1.3.5, 19.1.3.5, 8.2.1.3 Observations: Based on observation and interview, it was determined that the building construction type and height failed to meet regulations on two of six floors. Findings include: Observation on August 16, 2022, between 8:11 a.m. and 9:00 a.m., revealed the following areas lacked fire-rated ceiling protection and/or fire-protected structural steel beams. The facility shall verify the elements that maintain the two-hour fire-rated building assembly in these areas: A. (8:11 a.m.) Penthouse, elevator room; B. (8:15 a.m.) Penthouse, duct work room; C. (9:11 a.m.) Second floor, outside of the storage closet, in the glass, outside the corridor. Interview with the director of plant services and the manager of plant services on August 16, 2022, at 9:11 a.m., confirmed the above areas lacked fire-rated building assemblies. Plan of Correction:A. Working with KTH architects to secure a contractor to spray the structural beams, to maintain the 2 hour fire-rated building assembly B. Working with KTH architects to secure a contractor to spray the structural beams, to maintain the 2 hour fire-rated building assembly. C. On the second floor, the steel outside the x-ray storage closet provides the sub-framing for an exterior glass wall, and is not integral to the main structural support of the floor and building. KTH will provide a letter stating this as well as photographs. Therefore it is not required to be fire-sprayed to maintain a two hour fire-rated building assembly. To ensure compliance the Annual Life Safety Inspection Rounds will include visual inspections of fire-sprayed beams to maintain the 2 hour fire – rated building assembly. This will be reported at the bi-annual Safety Committee Meetings. NFPA 101 STANDARD Egress Doors Name – MAIN BUILDING Component – 01 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 Observations: Based on observation and interview, it was determined that the facility failed to meet regulations for doors with self-closing devices on two of six building levels. Findings include: Observation on August 16, 2022, between 8:23 a.m. and 10:10 a.m., revealed the following egress door deficiencies: A. (8:23 a.m.) Second floor emergency exit door, in the lab area, was difficult to open from the egress side; B. (10:10 a.m.) Third floor, stairwell D, had a conflicting “no exit sign” on the exit door. Interview with director of plant services on August 16, 2022, at 10:10 a.m., confirmed the above egress door deficiencies. Plan of Correction:A. Second Floor emergency exit door in the lab area had hardware replaced. B. Third floor, stairwell D “No Exit Sign” was removed from the exit door Monthly rounds will include testing of stairwell doors for proper operation and review of proper signage on exit doors. To ensure compliance, results of monthly rounding will be reported at the Safety Committee meetings and any issues will immediately be addressed by the Manager of Plant Services or his designee. NFPA 101 STANDARD Horizontal Exits Name – MAIN BUILDING Component – 01 Horizontal Exits Horizontal exits, if used, are in accordance with 7.2.4 and the provisions of 18.2.2.5.1 through 18.2.2.5.7, or 19.2.2.5.1 through 19.2.2.5.4. 18.2.2.5, 19.2.2.5 Observations: Based on observation and interview, the facility failed to maintain horizontal exit fire-rated doors on one of six levels. Findings include: Observation on August 16, 2022, at 9:48 a.m., revealed the fourth floor fire barrier doors, between sleep lab and the nutrition corridor, lacked fire-rated labels on the door, frame, and hardware. Interview with the director of plant services and the manager of plant services on August 16, 2022, at 9:48 a.m., confirmed the above horizontal exit fire barrier door lacked fire-rated labels. Plan of Correction:According to our life safety prints this is a one hour smoke wall, and according to regulations, the door has to be a 20 minute or 1.75 inch solid core wood door with closure. KTH will confirm the horizontal exit barrier door between the sleep lab and nutrition corridor . We are working with KTH Architects to update the Life Safety Prints for the hospitals buildings. Life Safety drawings will be updated as projects are completed and approved. KTH will conduct a walk-through verification of the prints. This will be reported at the Bi-monthly Safety Committee meetings. NFPA 101 STANDARD Emergency Lighting Name – MAIN BUILDING Component – 01 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 Observations: Based on observation and interview, it was determined that the facility failed to meet emergency light regulations on two of six stories. Findings include: 1. Observation on August 15, 2022, at 2:09 p.m., revealed the ground floor fire alarm panel room had an emergency light that failed to function when tested. Interview with director of plant services on August 15, 2022, at 2:09 p.m., confirmed the above battery back-up emergency light failed to function at the time of the survey. 2. Observation on August 16, 2022, at 9:56 a.m., revealed the second floor MRI hallway emergency light failed to function when tested. Interview with director of plant services on August 16, 2022, at 9:56 a.m., confirmed the above area battery back up emergency light failed to function at the time of the survey. Plan of Correction:1. Emergency Lights have been replaced in ground floor fire alarm panel room and MRI hallway. 2. Emergency Light inventory was updated. The Plant Services Manager will review monthly to ensure compliance. NFPA 101 STANDARD Exit Signage Name – MAIN BUILDING Component – 01 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) Observations: Based on document review and interview, the facility failed to maintain illuminated exit lighting, affecting the entire facility. Findings include: Document review on August 15, 2022, at 2:50 p.m., revealed the required exit lighting monthly inspections were not completed from September 2021 to May 2022. The inspection process was restarted in June 2022 following a survey finding. Interview with the director of plant services and the manager of plant services on August 15, 2022, at 2:50 p.m., confirmed the facility lacked required monthly inspection documentation for the illuminated exit lighting. Plan of Correction:1. It was noted that the PM for the monthly exit lights checks was turned off and it was restarted June 2022. To ensure compliance the Manager of Plant Services or Designee will review the monthly PMs to ensure they are assigned and printed. NFPA 101 STANDARD Vertical Openings – Enclosure Name – MAIN BUILDING Component – 01 Vertical Openings – Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 Observations: Based on observation and interview, the facility failed to maintain vertical opening requirements for one of over three vertical openings. Findings include: Observation on August 15, 2022, at 2:21 p.m., revealed the ground floor stairwell B had chairs and mechanical parts stored within the stair tower. Interview with director of plant services on August 15, 2022, at 2:21 p.m., confirmed the above items were stored within the stairtower. Based on observation and interview, the facility failed to maintain vertical opening requirements for one of over five vertical openings. Findings include: 1. Observation on August 16, 2022, between 9:03 a.m. and 9:04 a.m., revealed the following vertical shaft deficiencies: A. (9:03 a.m.) Fifth floor East wing fire door hardware lacked a label indicating the hardware was “fire exit hardware”; B. (9:04 a.m.) Fifth floor East wing had an unsealed section around a piece of conduit penetrating the shaft wall. Interview with the director of plant services and the manager of plant services on August 16, 2022, at 9:04 a.m., confirmed the above vertical shaft deficiencies. Plan of Correction:All items in the stairwell were removed 8.24.22. Plant services staff will be in-serviced on regulations related to stairwell storage. The stair tower will be inspected per the monthly rounding sheet and non-compliance will be corrected. A. Fifth floor east wing stair tower fire door hardware will be replaced with “fire exit hardware”. Completion by 10.14.22 B. Fifth floor east wing penetration of the shaft wall has been repaired 8.31.2022 Hazardous doors are inspected annually and report will be reviewed by the Plant Services Manager or his designee and deficiencies will be corrected and documented. This will be reported on at the bi-monthly Safety Committee Meetings NFPA 101 STANDARD Cooking Facilities Name – MAIN BUILDING Component – 01 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 Observations: Based on interview, the facility failed to maintain cooking facility regulation education with one of three kitchen staff. Findings include: Interview with one of three kitchen staff on August 15, 2022, at 2:31 p.m., revealed the staff member was unaware of the location of the manual pull activation for the hood suppression system over the cooking surface. Interview with the director of plant services on August 15, 2022, at 2:31 p.m., confirmed all kitchen staff shall be inserviced as to the location of the manual pull activation for the hood suppression system. Based on document review and interview, the facility failed to maintain cooking facilities for two of two kitchen hood and suppression systems. Findings include: 1. Document review on August 15, 2022, at 2:26 p.m., revealed the semi-annual inspection and testing report (dated October 27, 2021) for the kitchen suppression system stated “Wiring connections need proper junction box. Recommend removing non complaint residential gas hoses and install proper commercial cooking flex hoses.” The facility lacked documentation verifying the issues were corrected at the time of the survey. Interview with the director of plant services and the manager of plant services on August 15, 2022, at 2:26 p.m., confirmed there was no documentation verifying the above items were corrected. 2. Document review on August 15, 2022, at 2:38 p.m., revealed the semi-annual hood and duct cleaning service report (dated November 17, 2021) stated “Both systems need additional access panels. Both systems duct work is not welded properly leaks.” The facility lacked documentation verifying the items were corrected at the time of the survey. Interview with the director of plant services and the manager of plant services on August 15, 2022, at 2:38 p.m., confirmed there was no documentation to verify the above items were corrected. Plan of Correction: All new dietary staff will be inserviced on manual activation of the fire suppression system in the kitchen. The Director of Dietary Services will send a copy of the inservice to the Manager of Plant Services or his designee for review. 1. A. Wires will be removed from Ansul control box and installed into a NEC approved junction box . B. The existing non compliant residential flex hoses will be replaced with compliant commercial flex hoses. 2. We have contacted Allstate cleaning service for the location of the leaks in the ducts and placement of the access panels. Once location is identified leaks will be welded by an approved company. Semi-annual PM for Kitchen and Cafe exhaust hood cleaning and inspection has been added to ensure completion of semi-annual hood cleaning with deficiencies reviewed and repaired or replaced, it also includes that a copy of the service companies work order is retained and kept on file. This will be reviewed by the Plant Services Manager or designee. Any deficiencies and or corrections will be reported twice a year at the Safety Committee Meeting . Complete: 11.30.22 NFPA 101 STANDARD Fire Alarm System – Testing and Maintenance Name – MAIN BUILDING Component – 01 Fire Alarm System – Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 Observations: Based on document review and interview, the facility failed to maintain fire alarm systems for one of one fire alarm system, affecting the entire facility. Findings include: 1. Document review on August 15, 2022, between 11:12 a.m. and 12:43 p.m., revealed the following fire alarm deficiencies: A. (11:12 a.m.) The annual fire alarm inspection report completed on April 14, 2021, stated eighteen devices could not be inspected at that time and would need inspected at a future date. The annual fire alarm inspection report completed on March 25, 2022, revealed seven of the eighteen devices were not inspected and included one smoke and six heat detectors. B. (11:42 a.m.) The facility could not produce documentation verifying that the required two-year smoke detector sensitivity test was completed at the time of the survey. C. (11:55 p.m.) The facility could not produce documentation verifying that the required semi-annual visual inspection was completed. D. (12:43 p.m.) The annual fire alarm reports, reviewed at the time of the survey, revealed the medical office building detectors were not included in the inspection. Interview with the director of plant services and the manager of plant services on August 15, 2022, at 12:43 p.m., confirmed the above fire alarm deficiencies at the time of the survey. Plan of Correction:A. The 18 devices and 6 heat detectors will be inspected during the September inspection and testing of the fire alarm system by Johnson Controls. B. The quarterly testing and inspection of smoke detectors will be completed at the end of December by Johnson Controls. The report will be reviewed by the Manager of Plant Services or his designee. It will be presented at the following bi-monthly Safety Committee Meeting. C. Semi-annual visual inspection of the smoke detectors will be added to the hospital rounding sheet. The rounding sheet will be presented at the following bi-monthly Safety Committee Meeting. D. MOB smoke detectors were inspected by Johnson Controls. Names of the buildings where the detectors are located will be differentiated on the revised report. The report will be reviewed upon completion of the test by the Manager of Plant Services or his designee. NFPA 101 STANDARD Sprinkler System – Maintenance and Testing Name – MAIN BUILDING Component – 01 Sprinkler System – Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 Observations: Based on document review and interview, it was determined that the facility failed to maintain the clean agent device for one of one system. Findings include: Document review on August 15, 2022, at 2:12 p.m., revealed the last annual inspection report, completed on April 1, 2022, included the following note: “Pressure gauge was on the low end, cylinder was weighed this inspection. Cylinder weight was same as original fill weight. The problem could be a nitrogen leak or bad gauge.” The facility lacked documentation to verify this item was corrected at the time of the survey. Interview with the director of plant services and the manager of plant services on August 15, 2022, at 2:12 p.m., confirmed the annual inspection report indicated the above deficiency, and that there was no documentation to verify this item was corrected. Plan of Correction:Johnson Controls were contacted 8.24.22 for a quote to repair the deficiency listed on last inspection related to the pressure gauge/leak. Inspection results will be reviewed by the Plant Services Manager or his designee upon completion of inspection and reported at the bimonthly Safety Committee Meeting. NFPA 101 STANDARD Portable Fire Extinguishers Name – MAIN BUILDING Component – 01 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 Observations: Based on observation and interview, it was determined that the facility failed to maintain fire extinguishers for seven of over 50 portable fire extinguishers. Findings include: 1. Observation on August 15, 2022, between 2:40 p.m. and 3:10 p.m., revealed the following portable fire extinguisher deficiencies: A. (2:40 p.m.) Ground floor, behind the kitchen, near the old generator room, a portable fire extinguisher was missing the monthly inspection for July; B. (3:10 p.m.) First floor, maintenance shop area, behind the stairs, near voluntary services, a portable fire extinguisher was missing the monthly inspection for July. Interview with director of plant services on August 15, 2022, at 3:10 p.m., confirmed the above portable fire extinguishers lacked the monthly inspection for July. 2. Observation on August 16, 2022, between 8:08 a.m. and 10:06 a.m., revealed the following portable fire extinguisher deficiencies: A. (8:08 a.m.) Sixth floor penthouse had a portable fire extinguisher that lacked the monthly inspection for July; B. (8:13 a.m.) Sixth floor penthouse duct room had a portable fire extinguisher that lacked the monthly inspection for July; C. (8:56 a.m.) Fifth floor nurse station had a portable fire extinguisher that lacked the monthly inspection for July; D. (9:15 a.m.) Second floor, near EKG fire exit, a portable fire extinguisher lacked the monthly inspection for July; E. (10:06 a.m.) Fourth floor sleep lab nurse station had a portable fire extinguisher that lacked the monthly inspection for July; Interview with director of plant services on August 16, 2022, at 10:06 a.m., confirmed the above portable fire extinguishers lacked the monthly inspection for July. Plan of Correction:The seven fire extinguishers that were identified as not having been inspected have completed their monthly inspected and the tag has been initialed. Plant Services staff will be educated on the importance of completing monthly fire extinguisher inspections. 10 spot checks in the Main building will be done monthly to ensure that compliance is ongoing. This will continue until the next service inspection in May 2023. Any non-compliance will be reported at the bi-monthly Safety Committee meetings. NFPA 101 STANDARD Corridor – Doors Name – MAIN BUILDING Component – 01 Corridor – Doors 2012 EXISTING Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed. There is no impediment to the closing of the doors. Clearance between bottom of door and floor covering is not exceeding 1 inch. Roller latches are prohibited by CMS regulations on corridor doors and rooms containing flammable or combustible materials. Powered doors complying with 7.2.1.9 are permissible. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. Observations: Based on observation and interview, the facility failed to maintain corridor doors for one of over one hundred corridor doors. Findings include: Observation on August 16, 2022, at 10:07 a.m., revealed the patient room 449 door, on the East fourth floor, failed to positively latch in the frame. Interview with the director of plant services and the manager of plant services on August 16, 2022, at 10:07 a.m., confirmed the above corridor door lacked positive latching. Plan of Correction:The corridor door for patient room 449 East wing Fourth Floor will be adjusted to positively latch in the frame. Corridor door inspections for positively latching will be added to the monthly hospital round sheet. This will be monitored by the Manager of Plant Services or his designee. Any non-compliance will be repaired and reported at the bi-monthly Safety Committee meetings. NFPA 101 STANDARD Subdivision of Building Spaces – Smoke Barrie Name – MAIN BUILDING Component – 01 Subdivision of Building Spaces – Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. Observations: Based on observation and interview, it was determined that the facility failed to meet regulations for smoke barrier walls on one of six building levels. Findings include: Observation on August 16, 2022, at 9:40 a.m., revealed the second floor, above the fire doors at East toWest intersection, revealed a four-inch conduit penetration. Interview with director of plant services on August 16, 2022, at 9:40 a.m., confirmed the above conduit penetration. Plan of Correction:The four inch conduit penetration above the fire doors at the East and West intersection will be sealed with an approved UL stop gap penetration system. Inspection above the fire doors will be completed twice a year by the plant services department and reported at the Safety Committee meeting. NFPA 101 STANDARD Subdivision of Building Spaces – Smoke Barrie Name – MAIN BUILDING Component – 01 Subdivision of Building Spaces – Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9 Observations: Based on observation and interview, it was determined that the facility failed to meet regulations for fire/smoke barrier doors on two of six building levels. Findings include: Observation on August 15, 2022, between 8:23 a.m. and 9:43 p.m., revealed the following smoke/fire-rated door deficiencies: A. (8:23 a.m.) Ground floor, behind the old maintenance shop, door failed to latch due to airflow; B. (9:43 a.m.) Second floor fire/smoke doors, going to lab administrations, failed to positively latch in the frame. Interview with director of plant services on August 16, 2022, at 9:43 a.m., confirmed the above fire/smoke door deficiencies. Plan of Correction:A. Smoke doors before entering the old maintenance shop on the 1st floor that failed to latch will be adjusted to positively latch. B. Fire/smoke doors going to lab/administration that failed to latch will be adjusted to positively latch. Fire doors will be inspected monthly to ensure compliance. Any identified issues will be adjusted. This will be monitored by the Plant Services Manager or designee and non-compliance will be reported at the Safety Committee meetings NFPA 101 STANDARD Electrical Systems – Other Name – MAIN BUILDING Component – 01 Electrical Systems – Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided S-Tags, but are deficient. Chapter 6 (NFPA 99) Observations: Based on observation and interview, the facility failed to maintain and inspect electrical system requirements, per NFPA 70 and NFPA 99, on four of six building levels. Findings include: 1. Observation on August 16, 2022, between 8:15 a.m. and 2:45 p.m., revealed the following electrical deficiencies: A. (8:15 a.m.) Sixth floor penthouse, duct work room, an open breaker slot was exposing live electrical conductors for the panel labeled “6A1”; B. (8:16 a.m.) Sixth floor penthouse had a section of “dead front” cover missing and a partially removed section, exposing live electrical conductors for the panel panel labeled “6A”; C. (8:23 a.m.) Fifth floor mechanical room had a junction box for exhaust 4 that was missing the cover plate; D. (9:18 a.m.) Fourth floor server room had a receptacle missing the faceplate. Additionally, the top plug appeared to have burn markings, indicating a failure or heat build-up; E. (9:34 a.m.) Fourth floor shower room had an air mover with a cut cord wired into a junction box without a cover plate. The cord connection was hanging out of the junction box and was being secured with three wire nuts; F. (10:05 a.m.) Fourth floor, above the rated double doors for the sleep lab entrance, a junction box was missing the cover plate. G. (2:45 p.m.) Ground floor, old generator room, a junction box was open near the doorway to conference room. Reference: NFPA 70-314.28(C), NFPA 70-408.7, NFPA 70-406.6, and NFPA 70-110.27 Interview with the director of plant services and the manager of plant services on August 16, 2022, at 2:45 p.m., confirmed the above electrical system deficiencies. Plan of Correction:A. The sixth floor penthouse duct room with open breaker slot in the panel labeled 6A1 will be covered with an approved electric panel blank. B. The sixth floor penthouse with the dead front cover missing and the partially removed section labeled 6A will be covered with an approved insulated electric panel blank. C. The missing cover plate will be installed for exhaust fan 4. D. 4th floor server room receptacle missing faceplate will be replaced. The top plug will be inspected for failure. E. 4th floor shower room with wired air mover wired into a junction box. Air mover will be removed. F. Cover plate on fourth floor junction box above the double doors will be installed. G. Junction box near the doorway to conference room ground floor will have a knock out box plug added to the junction box. Completed repairs will be checked by the Plant Services Manager and reported at the Safety Committee Meeting. Plant service staff will be educated to identify and report electrical hazards, including inspection of electrical panels for missing blank covers and face plates, and approved wiring in construction areas. Work orders will be created for deficiencies found and repaired. Annual Life Safety Inspections will be done by plant services staff to ensure compliance. Work orders will be issued immediately to repair any deficiencies identified during the annual Life Safety Inspections. Deficiencies and corrections will be reported at the bi-monthly Safety Committee Meeting. NFPA 101 STANDARD Electrical Systems – Receptacles Name – MAIN BUILDING Component – 01 Electrical Systems – Receptacles Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover. If used in patient care room, ground-fault circuit interrupters (GFCI) are listed. 6.3.2.2.6.2 (F), 6.3.2.4.2 (NFPA 99) Observations: Based on observation and interview, the facility failed to maintain electrical receptacles for one of over one hundred rooms. Findings include: Observation on August 16, 2022, at 9:21 a.m., revealed the fifth floor dual diagnosis janitor closet had a receptacle, in close proximity to the sink, that was not protected by a ground fault circuit interrupter (GFCI). Interview with the maintenance supervisor on August 16, 2022, at 9:21 a.m., confirmed the above receptacle deficiency. Plan of Correction:A GFCI will be installed in the 5th floor dual diagnosis janitor closet. It will be tested for functionality. Education will be provided to the plant services staff related to NEC requirements for GFCI required locations. NFPA 101 STANDARD Electrical Systems – Essential Electric Syste Name – MAIN BUILDING Component – 01 Electrical Systems – Essential Electric System Alarm Annunciator A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator. 6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99) Observations: Based on observation and interview, the facility failed to meet the requirements for the essential electric alarm annunciator panel. Findings include: Observation on August 16, 2022, between 10:50 a.m. and 10:52 a.m., revealed the following deficiencies with the essential electric alarm annunciator panel: A. (10:50 a.m.) Alarm annunciator in the switchboard room failed to show normal power for the generator; B. (10:52 a.m.) Alarm annunciator in maintenance shop was blocked by scaffolding. The annuciator is in a location not readily accessible to maintenance staff. Interview with the director of plant operations on August 16, 2022, at 10:52 a.m., confirmed the above deficiences. Plan of Correction:A. Incandescent bulb has been ordered. Bulb will be replaced on arrival. B. Scaffolding was moved in the maintenance shop, on the day of the finding 8.17.22, to make annunciator readily accessible to the staff. Switchboard staff will be educated that annunciator run light must be identifiable for utility and or emergency power at all times. Education will be provided by Plant Services Manager or his designee. Blocking of the annunciator will be discussed in morning huddle with the plant services staff. Monthly PM for annunciator in switchboard will be created. Monthly PM for continued observation of clearance and functionality will stay on file for proper observation by Plant Services Manager or his designee, any non-compliance will be corrected immediately. NFPA 101 STANDARD Electrical Systems – Essential Electric Syste Name – MAIN BUILDING Component – 01 Electrical Systems – Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) Observations: Based on document review and interview, the facility failed to maintain essential electric system maintenance and testing for one of one emergency generator. Findings include: Document review on August 15, 2022, at 3:10 p.m., revealed the facility lacked documentation indicating that an annual fuel analysis report was conducted for the emergency generator. The last documented fuel analysis report was completed on July 25, 2021. Interview with the director of plant services and the manager of plant services on August 15, 2022, at 3:10 p.m., confirmed the annual fuel analysis report was not available at the time of the survey. Plan of Correction:Fuel analyst company was called on the day of the survey and completed the testing 8.25.22, report is being completed and will be sent to the Plant Service Manager, approximate time frame is by 9.30.2022. Plant Service Manager or designee will monitor annual testing through a checklist system NFPA 101 STANDARD Electrical Equipment – Power Cords and Extens Name – MAIN BUILDING Component – 01 Electrical Equipment – Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 Observations: Based on observation and interview, it was determined that the facility failed to meet regulations for electrical equipment on two of six building levels. Findings include: 1. Observation on August 15, 2022, between 2:20 p.m. and 3:00 p.m., revealed the following electrical equipment deficiencies: A. (2:20 a.m.) Ground floor kitchen area had a toaster and mixer plugged into a surge protector; B. (2:43 p.m.) Ground floor old generator room had a receptacle temporary wired to an extension cord. The cord was wrapped around the room and plugged into another temporary receptacle box; C. (2:46 p.m.) Ground floor meals on wheels office had an extension cord plugged into a fish tank; D. (2:50 p.m.) First floor WIC office had a surge protector plugged into a surge protector; E. (3:00 p.m.) First floor Covid shed had an extension cord that ran from the building electrically taped to another extension cord and plugged into a heater. Interview with director of plant services on August 15, 2022, at 3:00 p.m., confirmed the above electrical equipment deficiencies. 2. Observation on August 16, 2022, between 8:22 a.m. and 10:05 a.m., revealed the following electrical cord deficiencies: A. (8:22 a.m.) Fifth floor mechanical room had a chemical timer/pump system plugged into an extension cord. B. (10:05 a.m.) Third floor case manager office, next to stairwell C, had a microwave plugged into a surge protector. Interview with director of plant services and the manager of plant services on August 16, 2022, at 10:05 a.m., confirmed the office had a microwave plugged into a surge protector. Plan of Correction:All surge protectors were removed 8.17.2022. Staff will be educated through a ” Quality Spotlight” on how to properly use surge protectors. This will also be reinforced at the Safety Committee meeting, as it relates to the Hazard Surveillance Inspections that are completed. Hazardous Surveillance Inspection sheets are completed monthly, and will have “surge protector electronics only” added to the inspection checklist. Plant Services Manager or his designee will monitor non-compliance and report at the bi-monthly Safety Committee meetings. NFPA 101 STANDARD Gas Equipment – Testing and Maintenance Requi Name – MAIN BUILDING Component – 01 Gas Equipment – Testing and Maintenance Requirements Anesthesia apparatus are tested at the final path to patient after any adjustment, modification or repair. Before the apparatus is returned to service, each connection is checked to verify proper gas and an oxygen analyzer is used to verify oxygen concentration. Defective equipment is immediately removed from service. Areas designated for servicing of oxygen equipment are clean and free of oil, grease, or other flammables. Manufacturer service manuals are used to maintain equipment and a scheduled maintenance program is followed. 11.4.1.3, 11.5.1.3, 11.6.2.5, 11.6.2.6 (NFPA 99) Observations: Based on document review and interview, the facility failed to maintain medical gas systems for one of one medical gas system. Findings include: Document review on August 15, 2022, at 1:32 p.m., revealed the medical gas report, completed December 10, 2021, listed the following patient terminal outlets with deficiencies: patient room 492, OR1, OR2, OR3, and OR4. The facility lacked documentation verifying the deficiencies were corrected at the time of the survey. Interview with the director of plant services and the manager of plant services on August 15, 2022, at 1:32 p.m., confirmed the above medical gas report listed deficiencies. Plan of Correction:Working with Northeast Medical for a quote to repair med gas hoses in OR 1, 2, 3, and 4, and room 492. An annual PM has been added that includes “Ensure completion of annual med gas report by vendor and any deficiencies are reviewed and repaired or replaced.” The annual report will be reviewed by Plant Services Manager or his designee with the Med Gas Vendor and he will ensure that all deficiencies are repaired and reported at the Safety Committee annually. Initial Comments: Name – MOB Component – 02 Facility ID #541201 Component 02 Medical Office Building Based on a Relicensure Survey completed on August 15-16, 2022, it was determined that Bradford Regional Medical Center was not in compliance with the following requirements of the Life Safety Code for a new acute and ambulatory health care occupancy. This is a five-story, Type II (222), fire resistive building, which is fully sprinklered. Plan of Correction: NFPA 101 STANDARD Multiple Occupancies – Construction Type Name – MOB Component – 02 Multiple Occupancies – Construction Type Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows: * The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1 * The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters. 18.1.3.5, 19.1.3.5, 8.2.1.3 Observations: Based on observation and interview, it was determined that the building construction type failed to meet regulations on three of five floors. Findings include: Observation on August 15, 2022, between 11:00 a.m. and 12:45 p.m., revealed the following building construction type deficiencies: A. (11:00 a.m.) Third floor, above the ceiling tile, near elevator 3, had a fire protective coating missing on the steel beam; B. (12:02 p.m.) Third floor, based on the most recent drawings, should have a two-hour fire wall down the corridor, outside of the elevator. A two-hour protected area was not present in the barrier; C. (12:10 p.m.) Second floor, above the ceiling tile, near elevator 2, had about 2.5 feet of steel beam lacking a fire protective coating. D. (12:45 p.m.) First floor, outpatient SDS, bay 17-12, had missing fire-rated material where the ceiling met the vertical wall within the flutes. Interview with director of plant services on August 15, 2022, at 12:45 p.m., confirmed the above areas lacked fire-rated material. Plan of Correction:A. Approved protective fire coating will be applied to area near elevator 3 on 3rd floor. B. KTH sent the approved prints 4-09-20 showing the corridor wall as 30 minute. Our working life safety print was an oversite by KTH and was re-done C. Approved protective fire coating will be applied to area with missing coating near elevator 2, 2nd floor. D. Missing fire rated material in SDS bay 12-17 will be patched with an approved fire rated material Compliance: Plant Services Manager or designee will ensure that this is corrected and report at the next Safety Meeting. NFPA 101 STANDARD Doors with Self-Closing Devices Name – MOB Component – 02 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 Observations: Based on observation and interview, it was determined that the facility failed to meet regulations for doors with self-closing devices on two of five building levels. Findings include: Observation on August 15, 2022, between 11:30 a.m. and 12:38 p.m., revealed the following door closure deficiencies: A. (11:30 a.m.) Third floor, reception area, had a door closure propped open with a wedge; B. (1:05 p.m.) First floor, gift shop storage room, had a door closure propped open with a wedge. Interview with director of plant services on August 15, 2022, at 1:05 p.m. confirmed the above deficiencies. Plan of Correction:Door wedges were removed at the time of survey. Staff will be educated on the use of wedges through a “Quality Spotlight”. Compliance: Door wedges will be added to the hospital monthly rounding sheet. Non-Compliance will be addressed immediately, and monitored by the Manager of Plant Services. NFPA 101 STANDARD Exit Signage Name – MOB Component – 02 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) Observations: Based on document review and interview, the facility failed to maintain illuminated exit lighting, affecting the entire facility. Findings include: Document review on August 15, 2022, at 2:50 p.m., revealed the required monthly exit lighting inspections were not completed from September 2021 to May 2022. The inspection process was restarted in June 2022, following a survey finding. Interview with the director of plant services and the manager of plant services on August 15, 2022, at 2:50 p.m., confirmed the facility lacked required monthly inspections for illuminated exit lighting. Plan of Correction:It was noted that the PM for the monthly exit lights checks was turned off and it was restarted June 2022. To ensure compliance the Manager of Plant Services or Designee will review the monthly PMs to ensure they are assigned and printed. NFPA 101 STANDARD Fire Alarm System – Testing and Maintenance Name – MOB Component – 02 Fire Alarm System – Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 Observations: Based on document review and interview, the facility failed to maintain fire alarm systems for one of one fire alarm system, affecting the entire facility. Findings include: 1. Document review on August 15, 2022, between 11:12 a.m. and 12:43 p.m., revealed the following fire alarm deficiencies: A. (11:12 a.m.) The annual fire alarm inspection report completed on April 14, 2021, listed eighteen devices that could not be inspected at that time and would need inspected at a future date. The annual fire alarm inspection report completed on March 25, 2022, revealed seven of the eighteen devices that were not inspected, and included one smoke and six heat detectors. B. (11:42 a.m.) The facility could not produce documentation that the required two-year smoke detector sensitivity test was completed at the time of the survey. C. (11:55 p.m.) The facility could not produce documentation verifying that the required semi-annual visual inspection was completed. D. (12:43 p.m.) The annual fire alarm reports, supplied at the time of the survey, revealed the medical office building detectors were not included during the inspection. Interview with the director of plant services and the manager of plant services on August 15, 2022, at 12:43 p.m., confirmed the above fire alarm deficiencies. Plan of Correction:A. The 18 devices and 6 heat detectors will be inspected during the September inspection and testing of the fire alarm system by Johnson Controls. B. The quarterly testing and inspection of smoke detectors will be completed at the end of December by Johnson Controls. The report will be reviewed by the Manager of Plant Services or his designee. It will be presented at the following bi-monthly Safety Committee Meeting. C. Semi-annual visual inspection of the smoke detectors will be added to the hospital rounding sheet. The rounding sheet will be presented at the following bi-monthly Safety Committee Meeting. D. MOB smoke detectors were inspected by Johnson Controls. Names of the buildings where the detectors are located will be differentiated on the revised report. The report will be reviewed upon completion of the test by the Manager of Plant Services or his designee. NFPA 101 STANDARD Sprinkler System – Maintenance and Testing Name – MOB Component – 02 Sprinkler System – Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 Observations: Based on observation and interview, it was determined that the facility failed to meet requirements for sprinkler system maintenance and testing. Findings include: Observation on August 15, 2022, at 1:00 p.m., revealed the first floor data closet, near bay 10 in SDS, had a missing escutcheon plate around the sprinkler head. Interview with director of plant services on August 15, 2022, at 1:00 p.m., confirmed the sprinkler escutcheon plate was missing at the time of the survey. Plan of Correction:Missing escutcheon plate is ordered and being supplied by Armor for data closet near bay 10 in SDS, and will be replaced upon arrival. Education will be provided at the Safety Committee meeting related to the importance of escutcheon plates, sprinkler coverage area and how objects can affect spray radius. Hazardous surveillance inspection sheets include fire prevention equipment accessible and adequate. A “Quality Spotlight” will be sent out to all staff highlighting fire protection with sprinkler systems. Visual inspection of sprinkler heads every 6 months will be added to the facilities rounding sheets. NFPA 101 STANDARD Subdivision of Building Spaces – Smoke Barrie Name – MOB Component – 02 Subdivision of Building Spaces – Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. Observations: Based on observation and interview, it was determined that the building smoke barriers failed to meet regulations on two of five floors. Findings include: Observation on August 15, 2022, between 11:15 a.m. and 1:05 p.m., revealed the following smoke barrier deficiencies: A. (11:15 a.m.) Third floor electrical closet had a vertical conduit leading to the fourth floor that lacked fire caulking; B. (1:05 p.m.) First floor, near the building connector in SDS, had a grey and white wire penetration. Interview with director of plant services on August 15, 2022, at 1:05 p.m., confirmed the above deficiencies. Plan of Correction:1. Missing Fire Caulk on 3rd floor floor closet will be sealed with fire rated caulk. 2. Grey and white wire penetration on 1st floor near building connector in SDS will be sealed with an UL approved stop gap penetration system. Plant services staff will educate staff on hazardous surveillance. Vertical conduits will be added and checked on the monthly rounds sheet. Fire sealing will be a spotlighted issue in safety meetings so appropriate staff and vendors are informed of responsibilities of staff and contractors. Vertical conduits will be added and checked on the monthly rounds sheet NFPA 101 STANDARD Electrical Systems – Wet Procedure Locations Name – MOB Component – 02 Electrical Systems – Wet Procedure Locations Operating rooms are considered wet procedure locations, unless otherwise determined by a risk assessment conducted by the facility governing body. Operating rooms defined as wet locations are protected by either isolated power or ground-fault circuit interrupters. A written record of the risk assessment is maintained and available for inspection. 6.3.2.2.8.4, 6.3.2.2.8.7, 6.4.4.2 Observations: Based on observation and interview, it was determined that the facility failed to meet electrical system requirements on one of five stories. Findings include: Observation on August 15, 2022, at 1:10 p.m., revealed the ground floor therapy room had a hydrocollator plugged into a non-GFCI outlet. Interview with director of plant services on August 15, 2022, at 1:10 p.m., confirmed the above hydrocollator was not plugged into a GFCI-protected outlet. Plan of Correction:Ground Floor therapy room receptacle will be replaced with an approved GFCI receptacle. GFCI will be tested for functionality. Education will be provided to the plant services staff related to NEC requirements for GFCI required locations GFCI will be discussed in safety meeting related to wet locations, countertops and other requirements for GFCI required locations. GFCI will be inspected for proper placement on an annual basis and reported at the bi-monthly Safety Committee meetings. NFPA 101 STANDARD Electrical Systems – Essential Electric Syste Name – MOB Component – 02 Electrical Systems – Essential Electric System Alarm Annunciator A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator. 6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99) Observations: Based on observation and interview, the facility failed to meet essential electric alarm annunciator panel requirements. Findings include: Observation on August 16, 2022, between 10:50 a.m. and 10:52 a.m., revealed the following essential electric alarm annunciator panel deficiencies: A. (10:50 a.m.) Alarm annunciator in switch board room failed to show normal power for the generator; B. (10:52 a.m.) Alarm annunciator in maintenance shop was blocked by scaffolding. the annuciator was also in a location that was not readily accessible to maintenance staff. Interview with the director of plant operations on August 16, 2022, at 10:52 a.m., confirmed the above deficiencies. Plan of Correction:A. Incandescent bulb has been ordered. Bulb will be replaced on arrival. B. Scaffolding was moved in the maintenance shop, on the day of the finding 8.17.22, to make annunciator readily accessible to the staff. Switchboard staff will be educated that annunciator run light must be identifiable for utility and or emergency power at all times. Education will be provided by Plant Services Manager or his designee. Blocking of the annunciator will be discussed in morning huddle with the plant services staff. Monthly PM for annunciator in switchboard will be created. Monthly PM for continued observation of clearance and functionality will stay on file for proper observation by Plant Services Manager or his designee, any non-compliance will be corrected immediately. NFPA 101 STANDARD Electrical Systems – Essential Electric Syste Name – MOB Component – 02 Electrical Systems – Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) Observations: Based on document review and interview, the facility failed to maintain essential electric system maintenance and testing for one of one emergency generator. Findings include: Document review on August 15, 2022, at 3:10 p.m., revealed the facility lacked documentation verifying that an annual fuel analysis report was conducted for the emergency generator. The last documented fuel analysis report was completed on July 25, 2021. Interview with the director of plant services and the manager of plant services on August 15, 2022, at 3:10 p.m., confirmed the annual fuel analysis report was not available at the time of the survey. Plan of Correction:Fuel analyst company was called on the day of the survey and completed the testing 8.25.22, report is being completed and will be sent to the Plant Service Manager, approximate time frame is by 9.30.2022. Plant Service Manager or designee will monitor annual testing through a checklist system NFPA 101 STANDARD Electrical Equipment – Power Cords and Extens Name – MOB Component – 02 Electrical Equipment – Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 Observations: Based on observation and interview, it was determined that the facility failed to meet requirements for electrical equipment on three of five stories. Findings include: Observation on August 15, 2022, between 10:57 a.m. and 1:09 p.m., revealed the following electrical equipment deficiencies: A. (10:57 a.m.) Fourth floor, Dr. G office, had a coffee pot plugged into a surge protector; B. (12:24 p.m.) First floor, office behind the gift shop, had a heater plugged into a surge protector; C. (1:09 p.m.) Ground floor, maintenance shop, had a Keurig coffee maker plugged into a surge protector. Interview with director of plant services on August 15, 2022, at 1:09 p.m. confirmed the above electrical equipment deficiencies. Plan of Correction:All surge protectors were removed 8.17.2022. Staff will be educated through a ” Quality Spotlight” on how to properly use surge protectors. This will also be reinforced at the Safety Committee meeting, as it relates to the Hazard Surveillance Inspections that are completed. Hazardous Surveillance Inspection sheets are completed monthly, and will have “surge protector electronics only” added to the inspection checklist. Plant Services Manager or his designee will monitor non-compliance and report at the bi-monthly Safety Committee meetings. |