Initial Comments:
Name - MAIN BUILDING (ESRD) Component - 01
Facility ID# WP4J0101
Component 01
ESRD, Main Building
Based on a Recertification Survey completed on August 25, 2021, it was determined St. Christopher's Hospital For Children ESRD was not in compliance with the requirements of the Life Safety Code for an existing ESRD Health Care Facility. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 494.60(e)(1).
This is a five-story, Type II (222), fire resistive construction, with a ground floor and penthouse, which is partially sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Fire Alarm System - Testing and Maintenance
Name - MAIN BUILDING (ESRD) Component - 01
Fire Alarm Systems - 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.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Based on document review and interview, it was determined the facility failed to maintain the fire alarm system, affecting the entire facility.
Findings include:
1. Document review on August 25, 2021, at 8:30 a.m., revealed fire alarm inspection reports dated below contained deficiencies. Verification of repairs was not available at the time of the survey.
a) 1/18/2021 Report
b) 2/8/21 Report
c) 4/15/21 Report
d) 8/15/21 Report.
Exit Interview with the Administrator and Facility's Representative, on August 25, 2021, at 12:45 p.m., confirmed the deficiencies in the above reports had not been repaired.
Plan of Correction:The documents verifying the repairs were missing at the time of inspection. The Fire Alarm Service company produced the documentation verifying the repairs were completed . The 2/8/21 report is a continuation of the January (1/18/2021) inspection as the findings overlap. There were 34 Deficiencies listed in the report 24 messaging deficiencies were changed during the inspection, 8 deficiencies for missing signage at pull stations. These were corrected and new signage installed, There were 2 deficiencies that were related to Horns and Strobes. They were repaired at the time of the inspection. The April 2021 report listed 31 deficiencies all relate to messaging and all were corrected at the time of the inspection. There were no deficiencies in the July 16,2021 inspection report (there was no alarm inspection in August) . The documentation was forwarded to the hospital on Friday, 9/17/21. This paper work has been entered in the log book.
On 9/13/21 the Director Facilities Management met with the vendor and established the process and expectations for transmitting these reports timely. In order to avoid this in the future a standardized process has been developed for report review, verification that work orders are generated if needed and close out review. A log has been initiated and is included with the document book that shows all steps of the process have been completed.
This log will be reviewed monthly by the Director of Security and signed off by the Director Facilities Management.
The Director Facilities Management is responsible for compliance.
NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing
Name - MAIN BUILDING (ESRD) 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 automatic sprinkler system components, affecting the entire facility.
Findings include:
1. Observation on August 25, 2021, at 11:20 a.m., revealed two flow alarms with loose covers at the sprinkler risers in the boiler room.
Exit Interview with the Administrator and Facility's Representative, on August 25, 2021, at 12:45 p.m., confirmed there were two flow alarms with loose covers.
2. Observation on August 25, 2021, at 11:25 a.m., revealed the sprinkler system test header was missing covers on the hose connections.
Exit Interview with the Administrator and Facility's Representative, on August 25, 2021, at 12:45 p.m., confirmed the test header was missing covers on the hose connections.
Plan of Correction:1.The two loose covers on the flow alarms were tightened on 9/15/21
2.The test header covers were replaced on 9/15/2021 by the Sprinkler Contractor
The daily rounding checklist was revised to include the flow alarm covers and the test header covers. Visual inspection of these connections became a part of the daily rounding by the Shift Engineer starting on 9/16/2021. The inspection results will be entered into the daily log book maintained in the Boiler Room office. All Shift Engineers were trained on what to inspect and how to report their findings. This training was complete on 9/21/21
The lead shift engineer reviews the logs on a daily basis. The Director Facilities Management will review and sign the logs on a monthly basis for four consecutive months to ensure compliance and understanding.
The lead shift engineer is responsible for compliance.
NFPA 101 STANDARD
HVAC
Name - MAIN BUILDING (ESRD) Component - 01
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
20.5.2.1, 21.5.2.1, 9.2
Observations:
Based on document review and interview, it was determined the facility failed to maintain proper operation of heating, air conditioning, and ventilation equipment, affecting one of seven levels within the facility.
Findings Include:
1. Document review on August 25, 2021, at 8:30 a.m., revealed discrepancies on the building damper inspection report, dated July 2017. Verification of repairs was not available at the time of inspection.
Exit Interview with the Administrator and Facility's Representative, on August 25, 2021, at 12:45 p.m., confirmed the dampers required repair.
Plan of Correction:The documents verifying the repairs were produced by the Service Company and forwarded to the facilities department on 9/17/2021. Repairs to dampers 1129, 1130, 1132, 1137, dampers 1149, 1158, 1159 were removed from the list as they were no longer in system. Actions noted as completed in the July 2017 Safe Check report.
In order to avoid this issue in the future a document review of the Damper Inspection log will be completed upon receipt of the final inspection report. A sign off log has been developed to show that the review was complete and all deficiencies noted in the report were closed within 1 month of the report.
The log will be signed off by the facilities Director and maintained in the log book in the Facilities Department with the initial inspection report. The Facilities Director is responsible for compliance.
NFPA 101 STANDARD
Electrical Systems - Essential Electric Syste
Name - MAIN BUILDING (ESRD) 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 four 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 observation, document review and interview, it was determined the facility failed to maintain the emergency generator, which provides emergency power to the facility, for two of two emergency generators, affecting the entire component.
Findings include:
1. Document review and interview on August 25, 2021, at 8:30 a.m., revealed the facility could not provide documentation monthly conductance and weekly voltage checks had been performed on the emergency generator's maintenance free batteries since May 2021, for two of two generators.
Exit Interview with the Administrator and Facility's Representative, on August 25, 2021, at 12:45 p.m., confirmed the documentation was not available.
Plan of Correction:The missed documentation was the result of an individual performance issue. This individual is no longer with the organization. The monthly conductance test and weekly voltage test are current and up to date at this time.
A weekly PM was generated that includes the voltage checks as part of the weekly emergency generator inspections and the PM for the load test is generated monthly. A new electrician has been hired and will be starting 9/27/21, in the interim a contracted service is conducting these tests. Education on testing and documentation is provided prior to an individual performing the test.
The test documentation, including weekly battery voltage and results of monthly conductance test will be maintained with the emergency generator log books.
The date and results will be reviewed and signed off by the Director of Facilities monthly. Compliance will be reported at EOC Committee quarterly.
The Director Facilities Management is responsible for compliance.
NFPA 101 STANDARD
Gas Equipment - Cylinder and Container Storag
Name - MAIN BUILDING (ESRD) Component - 01
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.
*Greater than 300 but less than 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 hour 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 ensure medical gas cylinders were properly stored, affecting the entire component.
Findings include:
1. Observation on August 25, 2021, at 11:30 a.m., revealed the following medical gas cylinder storage deficiencies in the storage pen, at the exterior of the facility:
a) 17 E-sized med gas cylinders had rags and other housekeeping supplies stored on top of them;
b) 21 E-sized med gas cylinders were unprotected from the weather elements;
c) Two H-sized med gas cylinders were unprotected from the weather elements.
Exit Interview with the Administrator and Facility's Representative, on August 25, 2021, at 12:45 p.m., confirmed the deficiencies listed above.
Plan of Correction:The storage area was cleaned of debris on 8/26/2021. The need for the tanks was reviewed and several were removed to have the appropriate type and quantity. On 8/26/2021 the E size and H size cylinders were relocated under the protective roofing in a designated area marked by floor markings. Empty/Full signage has been provided and tanks have been properly secured. All work was completed by 9/21/21
Daily inspections of the Medical Gas Storage area started on 8/26/2021 and are currently in effect. The maintenance staff were instructed on how the storage area should be maintained. An automated daily PM has been developed delineating the specific things to be inspected (proper storage, security, cleanliness, full/ Empty storage)an inspection form was developed.
For the next four months, the inspection form will be reviewed and signed off by the Director of Facilities weekly. Ongoing this PM has been added to the Utilities Report shared with EOC monthly.
The Director of Facilities is responsible for compliance.
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