Initial Comments:
Name - MAIN BUILDING Component - 01
Facility ID 490401
Component 01
Main Building
Based on a Relicensure Survey completed on February 21, 2024, it was determined that Warren General Hospital was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.
This is a three-story, Type II (222), fire resistive building, with a penthouse and partial basement, that is partially sprinklered.
Plan of Correction:
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, the facility failed to ensure the division of building construction types on one of four building levels.
Findings include:
Observation on February 21, 2024, between 11:24 a.m. and 11:44 a.m., revealed the following rated fire wall deficiencies:
A. (11:24 a.m.) First floor, fire wall next to the elevators, separating rehabilitation and the corridor, had a penetration in the wall around a section of flexible conduit;
B. (11:28 a.m.) First floor, entrance 3, fire wall across from the elevators, separating "Davita Health" and the hospital, had two unsealed penetrations;
C. (11:37 a.m.) First floor, north side wall, separating "Davita Health" and the corridor, next to the public restroom, had an unsealed penetration measuring approximately 9"x 9". Additionally, there were various penetrations around conduit and piping sections throughout the rated north wall;
D. (11:44 a.m.) First floor, rated wall that separates medical records and the corridor, had two unsealed penetrations.
Interview with the maintenance supervisor and compliance officer on February 21, 2024, at 11:44 a.m., confirmed the listed penetrations existed in the rated walls.
Plan of Correction:Warren General Hospital Facilities Manager and Compliance Officer reviewed findings and will enforce the ceiling permit program to insure all penetrations are inspected and sealed correctly before the ceiling is closed back up. Observation A, B, C, and D have been corrected. We have completed work orders for each.
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 inspect and maintain the building construction type for a Type II (222)-rated building in two of ten rooms.
Findings include:
Observation on February 21, 2024, between 9:48 a.m. and 11:31 a.m., revealed the following building construction deficiencies:
A. (9:48 a.m.) The basement boiler room had steel beams in the ceiling, at six locations, that lacked fire protection coatings on the undersides of the bottom flanges.
B. (11:31 a.m.) The first floor entrance 3, above the lay-in ceiling tile, had a significant amount of air flow. Further investigation by the maintenance department revealed a damaged piece of flashing material between an old section of the roof and the new section. The damaged flashing created a draft above the lay-in ceiling tiles.
Interview with the maintenance supervisor, compliance officer, and maintenance technician on February 21, 2024, at 11:31 a.m., confirmed the deficiencies at the time of the survey.
Plan of Correction:Warren General Hospital facilities manager and compliance officer reviewed findings A and B.
A- facilities will get the proper fire rated material to cover the steel beams that lack fire protection. Work Order entered and materials on order.
B. facilities has investigated the significant air flow and corrected the issue on 3.6.2024.
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 two of four building levels.
Findings include:
Observation on February 21, 2024, between 10:31 a.m. and 11:54 a.m., revealed the following self-closing door deficiencies:
A. (10:31 a.m.) First floor loading dock, the dirty linen room was propped open and the door failed to close and latch in the frame;
B. (11:54 a.m.) Second floor soiled utility room door, next to room #2, had the self-closing device disconnected.
Interview with the facilities manager, maintenance supervisor, and compliance officer on February 21, 2024, at 11:54 a.m., confirmed the deficiencies.
Plan of Correction:Warren General Facilities Manager and Compliance Officer has reviewed the finding 0223.
Observation A and B have been corrected on 3.4.2024.
A- WGH facilities will create a PM to come out semi annually to have all doors inspected to insure doors close and latch.
B. WGH facilities will create a PM to come out semi annually to have all doors inspected to insure doors close and latch.
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 observation and interview, the facility failed to maintain exit signs for one of over five emergency exits.
Observation on February 21, 2024, between 10:53 a.m. and 11:35 a.m., revealed the following exit sign deficiencies:
A. (10:53 a.m.) The first floor laboratory exit sign lacked illumination;
B. (11:35 a.m.) The first floor corridor near the conference room lacked a directional exit sign above the smoke doors that could be seen when the doors are closed.
Interview with the maintenance technician on February 21, 2024, at 11:35 a.m., confirmed the exit sign deficiencies.
Plan of Correction:Warren General Facilities Manager and Compliance Officer reviewed observation 0293.
A. WGH facilities has a monthly inspection of all exit signs to make sure that all exit lights are lite at all times. WGH exit signs are 100% on generator power and do not use batteries. This was corrected on 3.5.2024
B. WGH facilities will install 1 exit sign in conference room A above main entrance and one in the hall with directional arrows and add the 2 new signs to the monthly inspection list with asset numbers. This was corrected on 3.5.2024.
NFPA 101 STANDARD
Hazardous Areas - Enclosure
Name - MAIN BUILDING Component - 01
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, the facility failed to maintain hazardous areas in one of more than ten hazardous areas.
Findings include:
Observation on February 21, 2024, between 11:15 a.m. and 11:17 a.m., revealed the following hazardous area deficiencies:
A. (11:15 a.m.) Basement mechanical room 1200 had an unsealed penetration in the left corner near the ceiling;
B. (11:17 a.m.) Basement mechanical room 1200 had an unsealed penetration above the rear man door.
Interview with the maintenance technician on February 21, 2024, at 11:17 a.m., confirmed the deficiencies.
Plan of Correction:WGH facilities manager and compliance officer reviewed observation 321.
Observation A&B for room 1200 is on the 1st floor for your record- not in basement as noted. Regardless, both A and B have been corrected on 3.4.2024. Facilities has made sure that all penetrations are sealed properly and has added to the rounds sheet to check all mechanical rooms for penetrations.
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, the facility failed to maintain smoke partitions to resist the passage of smoke on one of four building levels.
Findings include:
Observation on February 21, 2024, at 10:47 a.m., revealed the first floor smoke doors, located next to the kitchen, had an unsealed penetration above the lay-in ceiling.
Interview with the maintenance supervisor and compliance officer on February 21, 2024, at 10:47 a.m., confirmed the deficiency.
Plan of Correction:WGH Facilities manager and compliance officer have reviewed observation 0372.
Facilities will enforce the above ceiling permit program to insure all penetrations are inspected and sealed correctly before the ceiling is closed up.
This has been corrected on 2.23.2024
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, in one of over 100 rooms.
Findings include:
Observation on February 21, 2024, at 11:11 a.m., revealed the first floor pediatric waiting room had a junction box missing a cover plate above the lay-in ceiling tiles.
Reference: NFPA 70-314.28(C)
Interview with the maintenance supervisor and compliance officer on February 21, 2024, at 11:11 a.m., confirmed the junction box was missing a cover plate.
Plan of Correction:WGH facilities manager and compliance officer has reviewed observation 0911.
The first floor pediatric waiting room had a junction box missing a cover plate above the lay in ceiling tiles. To assure this doesn't happen again, WGH facilities will enforce the above ceiling permit program to insure all electrical work is inspected and correct before closing the ceiling.
This was corrected on 3.4.2024.
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 on three of five building levels.
Findings include:
Observation on February 21, 2024, between 11:19 a.m. and 11:45 a.m., revealed the facility failed to ensure ground fault circuit interrupter (GFCI) protection within six feet of sinks in the following locations:
A. (11:19 a.m.) Third floor, room #3326, storage room;
B. (11:45 a.m.) Second floor, room #209B, administration wing.
Interview with the facilities manager on February 21, 2024, at 11:45 a.m., confirmed the electrical outlet deficiencies.
Plan of Correction:WGH facilities manager and compliance officer has reviewed observation 0912.
Facilities has changed out receptacles to GFI outlets in room #3326 and room 209B.
Both have been completed on 3.4.2024
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, the facility failed to maintain electrical power cords for one of five building levels.
Findings include:
Observation on February 21, 2024, at 11:17 a.m., revealed the third floor room #3331 (staff breakroom) had a coffee pot and toaster oven plugged into a surge protector.
Interview with the facilities manager on February 21, 2024, at 11:17 a.m., confirmed the power cord deficiency.
Plan of Correction:WGH Facilities manager and compliance officer has reviewed observation 0920.
Facilities and the safety committee do monthly rounding to look for life safety hazards. If anything is found, a work order is submitted. Facilities and Compliance are part of this committee to assure its being monitored and enforced.
Education to staff was sent out as a reminder via email.
This was completed on 3.4.2024.
Initial Comments:
Name - BUILDING 03 Component - 03
Facility ID 490401
Component 03
1997 Building
Based on a Relicensure Survey completed on February 21, 2024, it was determined that Warren General Hospital was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.
This is a one-story, Type II (111), protected, non-combustible building, that is fully sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Spinkler System - Installation
Name - BUILDING 03 Component - 03
Spinkler System - Installation
2012 EXISTING
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)
Observations:
Based on observation and interview, the facility failed to install a sprinkler head, per NFPA requirements, in one of over twenty rooms.
Findings include:
Observation on February 21, 2024, at 10:02 a.m., revealed the first floor operating room did not have a sprinkler head present in the on-call room. The facility lacked sprinkler drawings to verify adequate sprinkler coverage.
Interview with the maintenance technician on February 21, 2024, at 10:02 a.m., confirmed the deficiency at the time of the survey.
Plan of Correction:WGH Facilities manager and Compliance officer have reviewed observation 0351.
WGH facilities has asked the sprinkler contactor to come in and install a new sprinkler head for the proper coverage.
This will be completed by 3.30.2024
NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing
Name - BUILDING 03 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 observation and interview, the facility failed to maintain the sprinkler system for one of over twenty-five sprinkler heads.
Findings include:
Observation on February 27, 2024, at 10:51 a.m., revealed the closet outside registration had a missing escutcheon plate that created an opening in the ceiling, possibly delaying sprinkler activation.
Interview with the maintenance technician on February 27, 2024, at 10:51 a.m., confirmed the sprinkler escutcheon plate was missing.
Plan of Correction:WGH facilities manager and compliance officer have reviewed observation 0353.
The missing escutcheon plate has been corrected on 2.22.2024.
To monitor this going forward facilities and the safety committee do monthly rounds in departments to look for life safety hazards. When anything is found a work order is submitted. Facilities and compliance are part of this committee for monitoring and enforcement.
NFPA 101 STANDARD
Electrical Systems - Receptacles
Name - BUILDING 03 Component - 03
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 on three of five building levels.
Findings include:
Observation on February 21, 2024, between 10:27 a.m. and 10:56 a.m., revealed the facility failed to ensure ground fault circuit interrupter (GFCI) protection within six feet of sinks in the following locations:
A. (10:27 a.m.) Main floor, emergency room triage;
B. (10:51 a.m.) Main floor, lab sink;
C. (10:56 a.m.) Main floor laboratory, workstation strip outlets.
Interview with the maintenance technician on February 21, 2024, at 11:45 a.m., confirmed the electrical outlet deficiencies.
Plan of Correction:WGH facilities manager and compliance officer reviewed observation 0912.
WGH facilities replaced the receptacles with GFIs for proper projection as noted in A, B and C.
This was completed on 2.22.2024.
NFPA 101 STANDARD
Electrical Equipment - Power Cords and Extens
Name - BUILDING 03 Component - 03
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, the facility failed to maintain electrical power cords in one of over twenty-five rooms.
Findings include:
Observation on February 21, 2024, at 11:52 a.m., revealed the penthouse had an extension cord powering medical air pumps.
Interview with the maintenance technician on February 21, 2024, at 11:52 a.m., confirmed the power cord deficiency.
Plan of Correction:WGH facilities manager and compliance officer reviewed observation 0920.
WGH facilities removed the extension cord and hard wired the medical equipment properly.
This was completed on 2.26.2024.
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