Initial Comments:
Name - TROY COMMUNITY HOSPITAL Component - 10
Facility ID# 460101
Component 10
Replacement Building
Based on a Relicensure Survey completed on February 15, 2023, it was determined that Troy Community Hospital, Inc., was not in compliance with the following requirements of the Life Safety Code for a new health care occupancy.
This is a one story, Type II (222), fire resistive building, that is fully sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Hazardous Areas - Enclosure
Name - TROY COMMUNITY HOSPITAL Component - 10
Hazardous Areas - Enclosure
2012 EXISTING
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4-hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1
Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of one floor.
Findings include:
1. Observation on February 15, 2023, at 10:26 a.m., revealed the Soiled Linen Room door hardware was damaged within the Building Services area.
Exit interview with the Facilities Manager on February 15, 2023, between 11:10 a.m., and 11:15 a.m., confirmed the hazardous area enclosure deficiency.
Plan of Correction:1.The Troy Community Hospital President is responsible for this action plan.
2. The soiled linen room within the Building Services area door hardware was replaced on 2/15/2023
3. Facility manager will round monthly for 3 months to confirm hardware on soiled linen room door is functional.
5. Compliance will be reported at EOC for 3 months whose membership includes hospital president.
6. All corrective actions will be completed prior to 4/01/2023.
NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing
Name - TROY COMMUNITY HOSPITAL Component - 10
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 one location, affecting one of one floor.
Findings include:
1. Observation on February 15, 2023, at 10:13 a.m., revealed wiring atop branch sprinkler piping, located at the B Hall entrance.
Exit interview with the Facilities Manager on February 15, 2023, between 11:10 a.m., and 11:15 a.m., confirmed the sprinkler system deficiency.
Plan of Correction:1. The Troy Community Hospital President is responsible for this action plan.
2. The wiring atop branch sprinkler piping located at the B Hall was corrected immediately upon discovery.
3. Facility staff will round monthly for 3 months to confirm no wiring atop branch sprinkler piping.
4. Compliance will be reported at EOC whose membership includes hospital President
5. All corrective actions will be completed prior to 4/01/2023.
NFPA 101 STANDARD
Corridor - Doors
Name - TROY COMMUNITY HOSPITAL Component - 10
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, it was determined the facility failed to maintain one corridor opening, affecting one of one floor.
Findings include:
1. Observation on February 15, 2023, at 10:03 a.m., revealed the ED Environmental Services closet door required adjustment to fully latch.
Exit interview with the Facilities Manager on February 15, 2023, between 11:10 a.m., and 11:15 a.m., confirmed the corridor opening deficiency.
Plan of Correction:1.The Troy community Hospital CNO is responsible for this action plan.
2. The ED Environmental Service closet door was adjusted to fully latch on 2/15/2023.
3.Designated EVS staff will round monthly for 3 months to confirm ED Environmental Service closet door fully latches.
4.Compliance will be reported at EOC for 3 months whose membership includes the hospital CNO.
5.All corrective actions will be completed prior to 4/1/2023.
NFPA 101 STANDARD
Gas Equipment - Cylinder and Container Storag
Name - TROY COMMUNITY HOSPITAL Component - 10
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, it was determined the facility failed to maintain cylinder storage/manifold room enclosures in one location, affecting one of one floor.
Findings include:
1. Observation on February 15, 2023, at 10:33 a.m., revealed the medical gas manifold room/cylinder storage room exterior door lacked proper signage.
Exit interview with the Facilities Manager on February 15, 2023, between 11:10 a.m., and 11:15 a.m., confirmed the cylinder storage/manifold room deficiency.
Plan of Correction:1.The TCH President is responsible for this action plan.
2.Temporary signage which includes the wording "Caution, Oxidizing Gas(es) Stored within No Smoking" has been placed on the medical gas manifold room/ cylinder storage room exterior door on 2/24/2023. Permanent signage which includes the wording "Caution, Oxidizing Gas(es) Stored within No Smoking" will be placed on the door prior to 04/01/2023.
3.Facility staff will round monthly for 3 months to confirm for permanent signage is on door.
4.Compliance will be reported at EOC for 3 months whose membership includes the hospital, President.
5. All the above corrective actions will be completed prior to 4/01/2023.
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