Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on May 9, 2023, at Kidspeace Orchard Hill Campus, it was determined there were no deficiencies identified with the requirements of 42 CFR 482.15.
Plan of Correction:
Initial Comments:
Name - MAIN BUILDING Component - 01
Facility ID# 01470100
Component 01
Main Building
Based on an Recertification survey completed May 9, 2023, it was determined that Kidspeace Orchard Hill Campus was not in compliance with the requirements of the Life Safety Code for an existing psychiatric health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 482.41(b).
This is a one story, Type V (111), protected, wood frame building, with a basement, that is fully sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Stairways and Smokeproof Enclosures
Name - MAIN BUILDING Component - 01
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2
Observations:
Based on observation and interview, it was determined the facility failed to maintain stair tower enclosures in three locations, affecting two of two floors.
Findings include:
1. Observation on May 9, 2023, between 11:12 a.m., and 11:53 a.m., revealed the following:
a. 11:12 a.m., the first floor, north core stair tower door enclosure lacked a fire-rated vision panel.
b. 11:14 a.m., non-rated, foam insulating materials within the basement-level, north core, stair tower wall enclosure.
c. 11:53 a.m., the south west, one, stair tower door was not fire-tight.
Exit interview on May 9, 2023, between 12:35 p.m., and 12:45 p.m., with the Facilities Manager, confirmed the stair tower enclosure deficiencies.
Plan of Correction:a. The vision panel will be replaced by June 15, 2023. Doors will be inspected annually, and repairs completed as needed.
b.The foam was removed and replaced with fire rated caulk on May 18, 2023. Use of materials will be monitored by the Safety Manager.
c. The door will be repaired by June 15, 2023. Doors will be inspected annually, and repairs completed as needed.
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 documentation review and interview, it was determined the facility failed to maintain emergency lighting in one location, affecting two of two floors.
Findings include:
1. Observation on May 9, 2023, at 12:20 p.m., revealed the facility lacked ninety-minute bleed (or drain) testing of the battery-operated lighting fixture, located within the transfer switch room.
Exit interview on May 9, 2023, between 12:35 p.m., and 12:45 p.m., with the Facilities Manager, confirmed the emergency lighting deficiency.
Plan of Correction:The 90 minute test was conducted on May 15, 2023. This has been added to our Preventative Maintenance (PM) Program to ensure future compliance and will be monitored by the Buildings and Grounds Department leadership.
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 observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in two locations, affecting one of two floors
Findings include:
1. Observation on May 9, 2023, between 10:07 a.m., and 12:12 p.m., revealed the following:
a. 10:07 a.m., storage items were located within eighteen inches of a sprinkler head, within the first floor, Core Storage Room.
b. 12:12 p.m., a missing escutcheon plate located within the first floor, south west, Electrical Room.
Exit interview on May 9, 2023, between 12:35 p.m., and 12:45 p.m., with the Facilities Manager, confirmed the the automatic sprinkler system deficiencies.
Plan of Correction:a. The items on the shelves were removed by Environmental Services staff on May 11, 2023. Monitoring of the closet will be done monthly by Hospital staff.
b.The escutcheon plate was installed on May 15, 2023. This will be monitored by the Environment of Care Committee during EOC tours.
NFPA 101 STANDARD
Corridor - Doors
Name - MAIN BUILDING Component - 01
Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. 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, it was determined the facility failed to maintain corridor openings, affecting one of two floors.
Findings include:
1. Observation on May 9, 2023, at 10:23 a.m., revealed in excess of one-eighth-inch between the lower level, north, Copier Room doors.
Exit interview on May 9, 2023, between 12:35 p.m., and 12:45 p.m., with the Facilities Manager, confirmed the corridor opening deficiencies.
Plan of Correction:The door will be repaired by June 15, 2023. Doors will be inspected annually and repaired as needed.
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 the facility failed to maintain two smoke barrier separation doors, affecting two of two floors.
Findings include:
1. Observation on May 9, 2023, between 10:47 a.m., and 12:14 p.m., revealed the following:
a. 10:47 a.m., the lower level, north, smoke barrier separation doors required adjustment to fully latch.
b. 12:14 p.m., the first floor, SR 221 smoke barrier separation door was damaged.
Exit interview on May 9, 2023, between 12:35 p.m., and 12:45 p.m., with the Facilities Manager, confirmed the smoke barrier separation door deficiencies.
Plan of Correction:a. The door was repaired on May 18, 2023. Doors will be inspected annually and repaired as needed.
b. This door was replaced on May 15, 2023. Doors will be inspected annually and repaired as needed.
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, readily identifiable, and separate from normal power circuits. 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 documentation review and interview, it was determined the facility failed to maintain the generator set, affecting two of two floors.
Findings include:
1. Observation on May 9, 2023, revealed the faciltiy lacked three year, four hour, generator set, load testing data.
Exit interview on May 9, 2023, between 12:35 p.m., and 12:45 p.m., with the Facilities Manager, confirmed the generator set deficiency.
Plan of Correction:The required test will be completed by June 15, 2023. This will be monitored by the Buildings and Grounds Department leadership through the Preventative Maintenance system for compliance.
NFPA 101 STANDARD
Electrical Equipment - Other
Name - MAIN BUILDING Component - 01
Electrical Equipment - Other
List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 10 (NFPA 99)
Observations:
Based on observation and interview, it was determined the facility failed to maintain the electrical system in one location, affecting one of two floors.
Findings include:
1. Observation on May 9, 2023, at 10:16 a.m., revealed items were located within thirty-six inches of electrical panels, located within the first floor, Core Storage Room.
Exit interview on May 9, 2023, between 12:35 p.m., and 12:45 p.m., with the Facilities Manager, confirmed the electrical systems deficiency.
Plan of Correction:The item was removed by the Environmental Services Department on May 11, 2023. Storage in these spaces will be monitored by the Environment of Care Committee during the EOC tours.
|