QA Investigation Results

Pennsylvania Department of Health
INDEPENDENCE HEALTH SYSTEM BUTLER MEMORIAL HOSPITAL
Building Inspection Results

INDEPENDENCE HEALTH SYSTEM BUTLER MEMORIAL HOSPITAL
Building Inspection Results For:


There are  114 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:
Name - MAIN BUILDING Component - 01

Facility ID # 023701
Component 01
Main Building

Based on a Relicensure Survey completed on February 7-8, 2024, it was determined that Butler Memorial Hospital was not in compliance with the requirements of the Life Safety Code for an existing acute care 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 six-story, Type II (222), fire resistive building, with a basement, that is partially sprinklered.





Plan of Correction:




NFPA 101 STANDARD
Building Construction Type and Height

Name - MAIN BUILDING Component - 01
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.


Observations:

Based on observation and interview, the facility failed to maintain the building contruction for a Type II (222) fire resistive building, for one of six building levels:

Findings include:

Observation on February 7, 2024, between 9:54 a.m. and 10:00 a.m., revealed the following fire wall deficiencies:
A. (9:54 a.m.) Ground floor, inside rated shaft GR#39, had an unsealed penetration;
B. (10:00 a.m.) Ground floor, mechanical room GR#11, had an unsealed penetration along the north wall.

Interview with the director of facilities on February 7, 2024, at 10:00 a.m., confirmed the fire rated wall deficiencies.






Plan of Correction:

A. On 2/14/24, Ground floor, inside rated shaft GR#39, had the penetration sealed with approved fire rated materials. W/O #526929.
B. On 2/14/2024, Ground floor, mechanical room GR#11, had the penetration sealed with approved fire rated materials. W/O #526930.

Butler Memorial Hospital has Contractor Guidelines that addresses penetrations. Facilities will review the Contractors Guidelines with the contractors to follow proper procedures for sealing penetrations with approved fire rated materials. Findings will be reported to the Safety Committee.


NFPA 101 STANDARD
Doors with Self-Closing Devices

Name - MAIN BUILDING Component - 01
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, the facility failed to maintain doors with self-closing devices on one of six building levels.

Findings include:

Observation on February 7, 2024, at 11:05 a.m., revealed the first floor storage room, located within the instrument decon area, had a self-closing door that would not close and latch in the frame.

Interview with the director of facilities on February 7, 2024, at 11:05 a.m., confirmed the door deficiency.








Plan of Correction:

On 2/13/24 the self-closing door was adjusted to latch within the frame. W/O #526931. These items will be inspected during EOC rounds and reported to Facilities Management for correction. Findings will be reported to the Safety Committee.


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 observation and interview, the facility failed to maintain the fire alarm system, affecting the main building.

Findings include:

Observation on February 8, 2024, at 11:22 a.m., revealed the fire alarm panel displayed a trouble mode. Through interview, the trouble mode was bypassed due to approved construction activities at the facility. The facility did not want the construction to inadvertently activate the alarm system. The alarm panel is still monitored by the facility dispatch center.

Interview with the director of facilities on February 8, 2024 at 11:22 a.m., confirmed the fire alarm panel deficiency.






Plan of Correction:

The Fire Alarm Panel has zones on bypass because of daily construction activities to avoid false alarms due to construction. These bypassed zones causes the trouble mode to the Fire Alarm Panel. The Fire Alarm Panel zones are restored to normal at the end of the daily construction activities and the Fire Alarm Panel is restored to NORMAL. The switchboard continues to receive all code red alarms and notifies 911 and internal overhead page. Hospital Electricians verify that the Fire Alarm Panel is NORMAL after removing the bypass zones because of construction. Reports of all code reds within the Hospital will be monitored for 100% compliance for 3 consecutive months. Findings will be reported to the Safety Committee.



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, observation, and interview, the facility failed to maintain sprinkler system maintenance and testing throughout the facility.

Findings include:

1. Document review on February 7, 2024, at 8:38 a.m., revealed the quarterly sprinkler inspection (dated October 13, 2023) noted that the five-year sprinkler gauges were changed in 2018. However, the new quarterly sprinkler inspection (dated January 19, 2024) noted that the five-year gauges were changed in 2019. Therefore, the five-year sprinkler gauge recalibration/change date was inconsistent throughout the quarterly reports.

2. Observation on February 7, 2024 between 10:55 a.m. and 1:46 p.m., revealed the following dates were listed on the sprinkler gauges:
A. (10:55 a.m.) Basement main riser had 2018 on the gauge;
B. (1:46 a.m.) Penthouse sprinkler gauges had 2023 on the gauge.

Interview with the director of facilities on February 7, 2024, at 1:46 p.m., confirmed the deficiency and scheduled the replacement of all gauges before the next quarterly inspection.






Plan of Correction:

1. On 2/7/24 FireFighters was contacted to schedule the 5 year sprinkler gauge replacements. FireFighters completed the work on 2/13/24. W/O# 527042. An event was created in the work order system to ensure future compliance. Findings will be reported to the Safety Committee.
2A. On 2/7/24 FireFighters was contacted replace gauges. FireFighters completed the work on 2/13/24. W/O# 527042. Findings will be reported to the Safety Committee.
2B. On 2/7/24 FireFighters was contacted replace gauges. FireFighters completed the work on 2/13/24. W/O# 527042. Findings will be reported to the Safety Committee.


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 February 7, 2024, at 11:54 a.m., revealed the third floor, southwest end, patient room M3112D failed to positively latch in the frame.

Interview with the director of facilities on February 7, 2024, at 11:54 a.m., confirmed the corridor door lacked positive latching.







Plan of Correction:

On 2/13/24 the patient door M3112D was adjusted and lubricated to latch within the frame. W/O #526932. These items will be inspected during EOC rounds and reported to Facilities Management for correction. Findings will be reported to the Safety Committee.


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, the facility failed to maintain smoke barrier doors on one of six building levels.

Findings include:

Observation on February 7, 2024, at 10:10 a.m., revealed the three main (ADD 23) door failed to positively latch in the frame.

Interview with the director of facilities on February 7, 2024, at 10:10 a.m., confirmed the door failed to latch.






Plan of Correction:

On 2/13/24 the three main (ADD 23) was repaired to positively latch within the frame. W/O #526927. These items will be inspected during EOC rounds and reported to Facilities Management for correction. Findings will be reported to the Safety Committee.


NFPA 101 STANDARD
Rubbish Chutes, Incinerators, and Laundry Chu

Name - MAIN BUILDING Component - 01
Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82

Observations:

Based on observation and interview, the facility failed to maintain vertical chutes on one of six building levels.

Findings include:

Observation on February 7, 2024, at 1:05 p.m., revealed the sixth floor access door to the trash chute, southwest side, soiled utility room, lacked positive latching.

Interview with the director of facilities on February 7, 2024, at 1:05 p.m., confirmed the trash chute door lacked positive latching.







Plan of Correction:

On 2/13/24 the trash chute door was cleaned and hinges lubricated to create a positive latch. W/O #526935. These items will be inspected during EOC rounds and reported to Facilities Management for correction. Findings will be reported to the Safety Committee.


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 meet electrical system requirements for three of three building components.

Findings include:

Document review on February 7, 2024, at 9:33 a.m., revealed the last documented three-year, four-hour load test was completed November 2020.

Interview with the director of facilities on February 7, 2024, at 9:33 a.m., confirmed the last date of the test and scheduled a new load test for May 2024.





Plan of Correction:

On 2/7/24 Cleveland Brothers was scheduled for April 29, 2024 to complete the 4-hour load test. PO generated. W/O #527054. Findings will be reported to the Safety Committee.


Initial Comments:
Name - NEW PATIENT TOWER BUILDING Component - 02

Facility ID # 023701
Component 02
Tower Building

Based on a Relicensure Survey completed on February 7-8, 2024, it was determined that Butler Memorial Hospital was not in compliance with the requirements of the Life Safety Code for an existing acute care 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 seven-story, Type II (222), fire resistive building, with a penthouse, that is fully sprinklered.





Plan of Correction:




NFPA 101 STANDARD
Vertical Openings - Enclosure

Name - NEW PATIENT TOWER BUILDING Component - 02
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 openings at four of twelve chute doors.

Findings include:

Observation on February 7, 2024, between 9:40 a.m. and 1:47 p.m., revealed the laundry and waste chute doors failed to properly close and self-latch in the following locations:

A.)(9:37 a.m.) Seventh floor trash room, trash chute input door;
B.)(10:22 a.m.) Sixth floor trash room, trash chute input door;
C.)(11:46 a.m.) Third floor housekeeping room, trash chute input door;
D.)(1:54 p.m.) First floor trash room, laundry chute discharge door.

Interview with the maintenance supervisor on February 7, 2024, at 1:47 p.m., confirmed the chute door deficiencies.






Plan of Correction:

A. On 2/13/24 the trash chute door was cleaned and hinges lubricated to create a positive latch. W/O #526906. These items will be inspected during EOC rounds and reported to Facilities Management for correction. Findings will be reported to the Safety Committee.
B. On 2/13/24 the trash chute door was cleaned and hinges lubricated to create a positive latch. W/O #526908. These items will be inspected during EOC rounds and reported to Facilities Management for correction. Findings will be reported to the Safety Committee.
C. On 2/13/24 the trash chute door was cleaned, hinges lubricated, adjusted the latch, and replaced the closure to create a positive latch. W/O #526909. These items will be inspected during EOC rounds and reported to Facilities Management for correction. Findings will be reported to the Safety Committee.
D. The trash chute door will be repaired to create a positive latch. Hinges need to be replaced and parts will be ordered when located. W/O #526924. These items will be inspected during EOC rounds and reported to Facilities Management for correction. Findings will be reported to the Safety Committee.


NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing

Name - NEW PATIENT TOWER BUILDING 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 document review, observation, and interview, the facility failed to maintain sprinkler system maintenance and testing throughout the facility.

Findings include:

Document review on February 7, 2024, at 8:38 a.m., revealed the quarterly sprinkler inspection (dated October 13, 2023) noted the five-year sprinkler gauges were changed in 2018. However, he new quarterly sprinkler inspection (dated January 19, 2024) note the five-year gauges were changed in 2019. Therefore, the five-year sprinkler gauge recalibration/change date was inconsistent throughout the quarterly reports.

Interview with the director of facilities on February 7, 2024, at 8:38 a.m., confirmed the deficiency and scheduled the replacement of all gauges before the next quarterly inspection.







Plan of Correction:

On 2/7/24 FireFighters was contacted to schedule the 5 year sprinkler gauge replacements. FireFighters completed the work on 2/13/24. W/O# 527042. An event was created in the work order system to ensure future compliance. Findings will be reported to the Safety Committee.



NFPA 101 STANDARD
Electrical Systems - Receptacles

Name - NEW PATIENT TOWER BUILDING Component - 02
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, per NFPA 70, in eleven of over fifty rooms.

Finding include:

Based on observation on February 7, 2024, between 9:40 a.m. and 1:48 p.m., the facility could not verify that ground fault circuit interrupter (GFCI) receptacles were installed in areas in close proximity to water outlets in the following locations:

A.)(9:40 a.m.) Seventh floor housekeeping room;
B.)(9:48 a.m.) Seventh floor nutrition room;
C.)(10:25 a.m.) Sixth floor housekeeping room;
D.)(10:29 a.m.) Sixth floor nutrition room;
E.)(10:43 a.m.) Sixth floor waiting room;
F.)(11:16 a.m.) Fifth floor nutrition room;
G.)(11:27 a.m.) Fifth floor family waiting room;
H.)(11:32 a.m.) Fifth floor medicine room;
I.)(11:38 a.m.) Fifth floor staff room;
J.)(1:47 p.m.) First floor staff lounge;
K.)(1:48 p.m.) First floor staff lounge, second outlets.

Interview with the maintenance supervisor on February 7, 2024, at 1:48 p.m., confirmed the receptacle deficiencies.








Plan of Correction:

"A. On 2/8/24 the GFCI was ordered to replace the existing receptacle that is within 5 ft of the water source. W/O#526911. Findings will be reported to the Safety Committee.
B. On 2/8/24 the GFCI was ordered to replace the existing receptacle that is within 5 ft of the water source. W/O#526913. Findings will be reported to the Safety Committee.
C. On 2/8/24 the GFCI was ordered to replace the existing receptacle that is within 5 ft of the water source. W/O#526912. Findings will be reported to the Safety Committee.
D. On 2/8/24 the GFCI was ordered to replace the existing receptacle that is within 5 ft of the water source. W/O#526916. Findings will be reported to the Safety Committee.
E. On 2/8/24 the GFCI was ordered to replace the existing receptacle that is within 5 ft of the water source. W/O#526917. Findings will be reported to the Safety Committee.
F. On 2/8/24 the GFCI was ordered to replace the existing receptacle that is within 5 ft of the water source. W/O#526918. Findings will be reported to the Safety Committee.
G. On 2/8/24 the GFCI was ordered to replace the existing receptacle that is within 5 ft of the water source. W/O#526919. Findings will be reported to the Safety Committee.
H. On 2/8/24 the GFCI was ordered to replace the existing receptacle that is within 5 ft of the water source. W/O#526921. Findings will be reported to the Safety Committee.
I. On 2/8/24 the GFCI was ordered to replace the existing receptacle that is within 5 ft of the water source. W/O#526923. Findings will be reported to the Safety Committee.
J. On 2/8/24 the GFCI was ordered to replace the existing receptacle that is within 5 ft of the water source. W/O#526922. Findings will be reported to the Safety Committee.
K. On 2/8/24 the GFCI was ordered to replace the existing receptacle that is within 5 ft of the water source. W/O#526922. Findings will be reported to the Safety Committee. "



NFPA 101 STANDARD
Electrical Systems - Essential Electric Syste

Name - NEW PATIENT TOWER BUILDING 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 meet electrical system requirements for three of three building components.

Findings include:

Document review on February 7, 2024, at 9:33 a.m., revealed the last documented three-year, four-hour load test was completed November 2020.

Interview with the director of facilities on February 7, 2024, at 9:33 a.m., confirmed the last test date and scheduled a new load test for May 2024.





Plan of Correction:

On 2/7/24 Cleveland Brothers was scheduled for April 29, 2024 to complete the 4-hour load test. PO generated. W/O #527054. Findings will be reported to the Safety Committee.


Initial Comments:
Name - NORTH WING & X BLDG Component - 03

Facility ID # 023701
Component 03
North Wing & X Building

Based on a Relicensure Survey completed on February 7-8, 2024, it was determined that Butler Memorial Hospital was not in compliance with the requirements of the Life Safety Code for an existing acute care 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 six-story, Type II (222), fire resistive building, that is partially sprinklered.





Plan of Correction:




NFPA 101 STANDARD
Building Construction Type and Height

Name - NORTH WING & X BLDG Component - 03
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.


Observations:

Based on observation and interview, the facility failed to maintain building construction type on one of six building levels.

Findings include:

Observation on February 8, 2024, at 7:00 a.m., revealed the first floor door 1 North 05, separating the north building from the annex building, was being kept open with a door wedge. The door has a magnet release; in the event of a fire, the door would have failed to release.

Interview with the director of facilities on February 8, 2024, at 7:00 a.m., confirmed the door deficiency and removed the door wedge on-site.




Plan of Correction:

On 2/8/24 the door wedge was removed. Staff will be educated on fire safety and not propping doors open. Evaluate the lock-down times of the door to improve workflow. Findings will be reported to the Safety Committee.


NFPA 101 STANDARD
Doors with Self-Closing Devices

Name - NORTH WING & X BLDG Component - 03
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, the facility failed to maintain doors with self-closing devices on one of six building levels.

Findings include:

Observation on February 7, 2024, at 2:03 p.m., revealed the X-building, fourth floor, door 3, had a self-closing door that would not close and latch in the frame.

Interview with the director of facilities on February 7, 2024, at 2:03 p.m., confirmed the door deficiency.






Plan of Correction:

On 2/13/24 the fourth floor door was adjusted and lubricated to latch within the frame. W/O #527057. These items will be inspected during EOC rounds and reported to Facilities Management for correction. Findings will be reported to the Safety Committee.


NFPA 101 STANDARD
Stairways and Smokeproof Enclosures

Name - NORTH WING & X BLDG Component - 03
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, the facility failed to maintain stair towers for one of three stair towers.

Findings include:

Observation on February 7, 2024, at 1:36 p.m., revealed the sixth floor North Stair B had stored housekeeping carts within the stair tower enclosure.

Interview with the director of facilities on February 7, 2024, at 1:36 p.m., confirmed the cart storage within the tower.





Plan of Correction:

On 2/10/24, the carts were removed and education provided to Housekeeping Supervisor. Housekeeping supervisor will educate the staff on appropriate storage of housekeeping carts. The area will be monitored for 3 months with 100% compliance achieved. W/O# 527060. Findings will be reported to the Safety Committee.


NFPA 101 STANDARD
Emergency Lighting

Name - NORTH WING & X BLDG Component - 03
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, the facility failed to maintain emergency lighting, in accordance with regulations, affecting one of three building components.

Findings include:

Observation on February 7, 2024, at 1:24 p.m., revealed the battery back-up emergency light unit in the X-building south wing penthouse generator room did not illuminate when the test button was pressed.

Interview with the director of facilities on February 7, 2024, at 1:24 p.m., confirmed the emergency light deficiency.





Plan of Correction:

On 2/9/24, the emergency light was replaced. W/O#526934. This item will be inspected during EOC rounds and reported to Facilities Management for correction. Findings will be reported to the Safety Committee.


NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing

Name - NORTH WING & X BLDG Component - 03
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, observation, and interview, the facility failed to maintain sprinkler system maintenance and testing throughout the facility.

Findings include:

Document review on February 7, 2024, at 8:38 a.m., revealed the quarterly sprinkler inspection (dated October 13, 2024) noted the five-year sprinkler gauges were changed in 2018. However, the hew quarterly sprinkler inspection (dated January 19, 2024) noted the five-year gauges were changed in 2019. Therefore, the five-year sprinkler gauge recalibration/change date was inconsistent throughout the quarterly reports.

Interview with the director of facilities on February 7, 2024, at 8:38 a.m., confirmed the deficiency and scheduled the replacement of all gauges before the next quarterly inspection.





Plan of Correction:

On 2/7/24 FireFighters was contacted to schedule the 5 year sprinkler gauge replacements. FireFighters completed the work on 2/13/24. W/O# 527042. An event was created in the work order system to ensure future compliance. Findings will be reported to the Safety Committee.


NFPA 101 STANDARD
Portable Fire Extinguishers

Name - NORTH WING & X BLDG Component - 03
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, the facility failed to maintain portable fire extinguishers on one of six building levels.

Findings include:

Observation on February 7, 2024, at 10:32 a.m., revealed the ground floor south wing IT storage room had blocked access to the fire extinguisher.

Interview with the director of facilities on February 7, 2024, at 10:32 a.m., confirmed access was blocked by equipment.





Plan of Correction:

On 2/13/24 the room was reorganized to provide adequate access to the fire extinguisher. The IT Staff was educated on fire safety and access of fire extinguishers. Monitor the room for 3 months. Findings will be reported to the Safety Committee. WO#527062


NFPA 101 STANDARD
Electrical Systems - Essential Electric Syste

Name - NORTH WING & X BLDG Component - 03
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 meet electrical system requirements for three of three building components.

Findings include:

Document review on February 7, 2024, at 9:33 a.m., revealed the last documented three-year, four-hour load test was completed November 2020.

Interview with the director of facilities on February 7, 2024, at 9:33 a.m., confirmed the last test date and scheduled a new load test for May 2024.




Plan of Correction:

On 2/7/24 Cleveland Brothers was scheduled for April 29, 2024 to complete the 4-hour load test. PO generated. W/O #527054. Findings will be reported to the Safety Committee.


NFPA 101 STANDARD
Gas Equipment - Cylinder and Container Storag

Name - NORTH WING & X BLDG Component - 03
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:

Based on observation and interview, the facility failed to maintain gas equipment storage requirements on one of six floors.

Findings include:

Observation on February 7, 2024, at 1:28 p.m., revealed the second floor ambulance entrance had the following deficiencies:
A. (1:28 p.m.) Unsecured oxygen tank;
B. (1:28 p.m.) Green oxygen cylinder container was not labeled as full or empty.

Interview with the director of facilities on February 7, 2024, at 1:28 p.m., confirmed the deficiencies.




Plan of Correction:

A. On 2/8/24, the Oxygen cylinder was secured. W/O#527066. This will be monitored by the ED Director for 3 consecutive months to verify 100% compliance of O2 cylinders being secured. Findings reported to the Safety Committee.
B. On 2/12/24 the holders were appropriately labeled for Full or partial oxygen and will be monitored by the ED Director for 3 consecutive months to verify 100% compliance. Findings will be reported to the Safety Committee.