7ixf21_2567.pdf - IN.gov

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

07/27/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE

(X4) ID

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SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

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IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

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DATECROSS-REFERENCED TO THE APPROPRIATE

INDIANAPOLIS, IN 46290

15C0001183 05/15/2017

MULTI SPECIALTY SURGERY CENTER

10601 N MERIDIAN ST SUITE 100

01

K 0000

Bldg. 01

A Life Safety Code Recertification

Survey was conducted by the Indiana

State Department of Health in accordance

with 42 CFR 416.44(b).

Survey Date: 05/15/17

Facility Number: 012823

Provider Number: 15C0001183

AIM Number: NA

At this Life Safety Code survey, Multi

Specialty Surgery Center was found not

in compliance with Requirements for

Participation in Medicare/Medicaid, 42

CFR Subpart 416.44(b), Life Safety from

Fire and the 2012 edition of the National

Fire Protection Association (NFPA) 101,

Life Safety Code (LSC), Chapter 21,

Existing Ambulatory Health Care

Occupancies.

The facility, located on the first floor of a

two story building with a partial

basement was determined to be of Type II

(000) construction and was fully

sprinklered. The facility has a fire alarm

system with smoke detection in the

corridors.

Quality Review completed on 05/19/17 -

K 0000

FORM CMS-2567(02-99) Previous Versions Obsolete

Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determined that

other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to

continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

_____________________________________________________________________________________________________Event ID: 7IXF21 Facility ID: 012823

TITLE

If continuation sheet of 45

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DA

NFPA 101

Multiple Occupancies

Multiple Occupancies - Sections of

Ambulatory Health Care Facilities

Multiple occupancies shall be in accordance

with 6.1.14.

Sections of ambulatory health care facilities

shall be permitted to be classified as other

occupancies, provided they meet both of the

following:

* The occupancy is not intended to serve

ambulatory health care occupants for

treatment or customary access.

* They are separated from the ambulatory

health care occupancy by a 1 hour fire

resistance rating.

Ambulatory health care facilities shall be

separated from other tenants and

occupancies and shall meet all of the

following:

* Walls have not less than 1 hour fire

resistance rating and extend from floor slab

to roof slab.

* Doors are constructed of not less than

1-3/4 inches thick, solid-bonded wood core

or equivalent and is equipped with positive

latches.

* Doors are self-closing and are kept in the

closed position, except when in use.

* Windows in the barriers are of fixed fire

window assemblies per 8.3.

Per regulation, ASCs are classified as

Ambulatory Health Care Occupancies,

regardless of the number of patients served.

20.1.3.2, 21.1.3.3, 20.3.7.1, 21.3.7.1,42 CFR

416.44

K 0131

Bldg. 01

Based on observation and interview, the

facility failed to ensure 1 of 1 fire barriers

K 0131 1. All fire barriers in the facility

will be inspected by a contractor.

The contractor will ensure that

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that separated other occupancies were

protected to maintain the one hour fire

resistance rating of the fire barrier. NFPA

101 2012 edition 8.3.5.6.1 states

membrane penetrations for cables cable

trays conduits, pipes, tubes, combustion

vents and exhaust vents, wires, and

similar items to accommodate electrical,

mechanical, plumbing, and

communications systems that pass

through a membrane of a wall, floor, or

floor/ceiling assembly constructed as a

fire barrier shall be protected by a

firestop system or device. 8.3.5.6.2 The

firestop system or device shall be tested

in accordance with ASTM E 814,

Standard Test Method for Fire Test of

Through Penetration Fire stops, or

ANSI/UL 1479, Standard for Fire Tests

of Through-Penetration Firestops. This

deficient practice could affect all

occupants.

Findings include:

Based on observations with the Clinical

Manager during a tour of the facility from

1:30 p.m. to 3:00 p.m. on 05/15/17, all

penetrations of drywall and all gaps in

between drywall sections and the deck of

the flooring above along the north and

west wall of the tenant separation fire

barrier wall in the lobby above the

suspended ceiling by the vending

any gaps or penetrations are

sealed, in an approved manner,

to maintain their rating.

2. The clinical manager

will ensure that all future work is

monitored to ensure that an

approved firestop is used on any

penetrations in fire barriers.

Center policy LSC 8.00 Interim

Life Safety Measures will be

followed to ensure the integrity of

the fire barriers are maintained.

3. The clinical manager is

responsible to ensure that this

deficiency has been corrected

and that on-going compliance is

maintained.

The center's floor plan with fire

barriers is attached as exhibit 2.

Policy LSC 8.00 Interim Life

Safety Measures is attached as

exhibit 4. Statement of work from

contracted service provide is

exhibit 15.





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machines were filled with foam. Based

on interview at the time of the

observations, the Clinical Manager stated

she was unaware of the fire resistance

rating of the foam used to fill the

penetrations and gaps and acknowledged

the use of foam did not maintain the

minimum fire resistance rating for the

tenant separation fire wall.

NFPA 101

Illumination of Means of Egress

Illumination of Means of Egress

Illumination of means of egress, including

exit discharge, is arranged in accordance

with 7.8 and shall be either continuously in

operation or capable of automatic operation

without manual intervention.

20.2.8, 21.2.8, 7.8

K 0281

Bldg. 01


facility failed to ensure continuity of

egress lighting for 1 of 4 exits. For the

purposes of this requirement, exit

discharge shall include only designated

stairs, aisles, corridors, ramps, escalators,

walkways and exit passageways leading

to a public way. This deficient practice

could affect four patients, staff and

visitors if needing to exit the facility from

the south exit door.

K 0281 1. Egress lighting will be added

to the south exit discharge by a

contractor.

2. Egress lighting has been

confirmed at all exits. Visual

confirmation that egress lighting

is visible and functioning has

been added to the facilities

monthly PM checklist.


responsible to ensure that the

facility performs environmental

rounding on a regular basis.

The center's monthly PM

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Finding include:



1:30 p.m. to 3:00 p.m. on 05/15/17, the

south exit discharge was not provided

with egress lighting. Based on interview

at the time of the observations, the

Clinical Manager acknowledged the

south exit discharge was not provided

with egress lighting.

Checklist is attached as exhibit 1.

Statement of work regarding the

addition of egress lighting is

exhibit 17. Picture of egress

lighting attached as image 2.

NFPA 101

Emergency Lighting

Emergency Lighting

Emergency lighting of at least 1-1/2 hour

duration is provided automatically in

accordance with 7.9.

20.2.9.1, 21.2.9.1, 7.9

K 0291

Bldg. 01

Based on record review, observation and

interview; the facility failed to document

monthly and annual testing for 4 of 4

battery backup lights in accordance with

LSC 7.9. Section 7.9.3.1.1 states testing

of emergency lighting systems shall be

permitted to be conducted as follows:

(1) Functional testing shall be conducted

monthly, with a minimum of 3 weeks and

a maximum of 5 weeks between tests, for

not less than 30 seconds, except as

otherwise permitted by 7.9.3.1.1(2).

(2) The test interval shall be permitted to

be extended beyond 30 days with the

approval of the authority having

K 0291 1. 30 second and 90 minute

testing will be performed on the

center's battery powered

emergency lights. The center's

monthly PM checklist has been

expanded to include the location

of each battery powered light for

the required monthly thirty second

test. The center's equipment and

PM schedule includes

documentation for the annual

ninety minute functional testing.

2. Monthly and testing for

the center's battery powered

lights has been added to

the center's monthly PM

checklist. Annual testing has

been added to the center's

equipment list and PM schedule.

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jurisdiction.

(3) Functional testing shall be conducted

annually for a minimum of 1 1/2 hours if

the emergency lighting system is battery

powered.

(4) The emergency lighting equipment

shall be fully operational for the tests

required by 7.9.3.1.1(1) and (3).

(5) Written records of visual inspections

and tests shall be kept by the owner for

inspection by the authority having

jurisdiction.

This deficient practice could affect all

patients, staff and visitors in the facility.

Findings include:

Based on review of "Preventive

Maintenance - Task: Battery-Powered

Emergency Light Test" & "Preventive

Maintenance - Task: Generator Powered

Emergency Light Test" documentation

dated 04/18/17 and 05/02/17 with the

Clinical Manager during record review

from 9:50 a.m. to 1:30 p.m. on 05/15/17,

monthly testing documentation for each

battery powered light in the facility was

not itemized by location. The

aforementioned documentation stated

"check operation of all lamps" and "push

test button or turn off power for 30

seconds." In addition, based on

telephone interview with the Building

Maintenance Manager at the time of


responsible to ensure that

environmental rounding and

testing occurs on a routine basis.



The center's equipment list and

PM schedule has been added as

exhibit 3.





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record review, it could not be assured the

aforementioned documentation pertained

to monthly battery operated light testing.

The Building Maintenance Manager

stated the aforementioned documentation

pertained to battery testing in facility exit

signs. Annual 90 minute functional

testing documentation for each battery

powered emergency light in the facility

within the most recent twelve month

period was also not available for review.



1:30 p.m. to 3:00 p.m. on 05/15/17,

battery powered emergency lights were

located in each of three operating rooms

(OR) where general anesthesia is utilized

and one battery powered emergency light

system was located on the exit sign at the

north exit vestibule for biohazard waste

pickup. The north exit battery light

system also illuminated a light for the

generator location which functioned

when its test button was pushed. The

battery powered light in OR1 illuminated

when its test button was pushed but the

lights in OR2 and OR3 could not be

tested because access was restricted due

to surgeries in the rooms.

NFPA 101 K 0341





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Fire Alarm System - Installation

Fire Alarm - Installation

A fire alarm system is installed with systems

and components approved for the purpose

in accordance with NFPA 70, National

Electric Code, and NFPA 72, National Fire

Alarm Code to provide effective warning of

fire in any part of the building. In areas not

continuously occupied, detection is installed

at each fire alarm control unit. In new

occupancy, detection is also installed at

notification appliance circuit power

extenders, and supervising station

transmitting equipment. Fire alarm system

wiring or other transmission paths are

monitored for integrity.

20.3.4.2.1, 21.3.4.1, 9.6

Bldg. 01

1. Based on observation and interview,

the facility failed to ensure 1 of 1 fire

alarm control units, located in an area

that was not continuously occupied, was

provided with automatic smoke detection

to ensure notification of a fire at that

location before it is incapacitated by fire.

LSC 9.6.1.3 requires a fire alarm system

to be installed, tested, and maintained in

accordance with NFPA 70, National

Electrical Code and NFPA 72, National

Fire Alarm and Signaling Code. NFPA

72, 2010 Edition, Section 10.15 requires

in areas that are not continuously

occupied, automatic smoke detection

shall be provided at the location of each

fire alarm control unit(s), notification

appliance circuit power extenders, and

supervising station transmitting

equipment to provide notification of a

K 0341 1. A contractor has been hired to

add automatic smoke detection to

the main alarm control unit

located in the main entrance

vestibule. A remote annunciator

will also been added to the

surgery center suite.

2. The fire system will be tested

at regular intervals by the center's

contracted service provider.

Testing will be verified by the

center's safety officer utilizing the

Equipment list and PM schedule

checklist.


responsible to ensure that the

center maintains appropriate

documentation and the

preventative maintenance is

performed on schedule.



exhibit 3. A work order for the

addition of automatic smoke

detection to the main alarm

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fire in that location. Exception: where

ambient conditions prohibit installation

of automatic smoke detection, automatic

heat detection shall be permitted.

A.10.15 permits the use of a heat detector

if ambient conditions are not suitable for

smoke detection. It is important to also

evaluate whether the area is suitable for

the control unit. This deficient practice

could affect all patients, staff and visitors

in the facility.

Findings include:



1:30 p.m. to 3:00 p.m. on 05/15/17,

automatic smoke detection was not

provided at the main fire alarm control

unit located in the main entrance

vestibule for the facility. A fire alarm

system heat detector was located in the

vestibule but a reason or rationale for the

omission of automatic smoke detection at

the main fire alarm control unit location

was not known. Based on interview at

the time of the observation, the Clinical

Manager acknowledged automatic smoke

detection was not provided at the main

fire alarm control unit location.


the facility failed to ensure 1 of 1 fire

alarm control units, located in an area

control unit and remote

annunciator is attached as exhibit

19.





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that was not continuously occupied, was

provided with annunciation readily

accessible to responding personnel to

facilitate an efficient response to the fire

situation. LSC 9.6.1.3 requires a fire

alarm system to be installed, tested, and

maintained in accordance with NFPA 70,

National Electrical Code and NFPA 72,

National Fire Alarm and Signaling Code.

NFPA 72, 2010 Edition, Section

10.16.3.1 states all required annunciation

means shall be readily accessible to

responding personnel. Section 10.16.3.2

states all required annunciation means

shall be located as required by the

authority having jurisdiction to facilitate

an efficient response to the fire situation.

Section A.10.16.3 states the primary

purpose of fire alarm system

annunciation is to enable responding

personnel to identify the location of a fire

quickly and accurately and to indicate the

status of emergency equipment or fire

safety functions that might affect the

safety of occupants in a fire situation.

Section 10.12.5 states the trouble

signal(s) shall be located in an area where

it is likely to be heard. This deficient

practice could affect all patients, staff and

visitors in the facility.

Findings include:






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1:30 p.m. to 3:00 p.m. on 05/15/17, the

main fire alarm control unit was located

in the main entrance vestibule for the

building. A remote annunciator was not

located within the surgery center suite.

Based on interview at the time of the

observations, the Clinical Manager

acknowledged a remote annunciator was

not located within the surgery center

suite.

NFPA 101

Fire Alarm System - Testing and

Maintenance

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

K 0345

Bldg. 01

Based on observation and interview, the K 0345 1. Access to the electrical panel 06/07/2017 12:00:00AM





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facility failed to ensure 1 of 1 fire alarm

systems was maintained in accordance

with the applicable requirements of

NFPA 72, National Fire Alarm Code.

NFPA 72, 2010 Edition, Section 10.5.5.1

states connections to the light and power

service shall be on a dedicated branch

circuit(s). Circuit disconnecting means

shall have a red marking, shall be

accessible only to authorized personnel,

and shall be identified as FIRE ALARM

CIRCUIT. The location of the circuit

disconnecting means shall be

permanently identified at the fire alarm

control unit. Section 10.5.5.4 states an

overcurrent protective device of suitable

current carrying capacity and capable of

interrupting the maximum short circuit

current to which it may be subject shall

be provided in each ungrounded

conductor. The dedicated branch

circuit(s) and connections shall be

protected against physical damage. This

deficient practice could affect all patients,

staff and visitors.

Findings include:



1:30 p.m. to 3:00 p.m. on 05/15/17,

access to the fire alarm system breaker

located in the electrical panel in the first

floor electrical room by the elevator

containing the fire alarm circuit

will be restricted to authorized

personnel and locked at all

times. Building management has

added a lock to the electrical

room and signage indicating

authorized personnel only.

2. The electrical panel has been

added to the facilities

environmental rounding checklist

to ensure it is secured from

unauthorized access.



environmental rounding occurs on

a routine basis.



A picture of the door lock and

signage is included as image 1.





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machine room was not restricted to

authorized personnel. The corridor entry

door to the room, the electrical panel

containing the breaker and the breaker

were each not locked. Based on

interview at the time of the observations,

the Clinical Manager acknowledged

access to the fire alarm system breaker

was not restricted to authorized

personnel.

NFPA 101

Fire Alarm System - Out of Service

Fire Alarm - Out of Service

Fire alarms that are out of service for 4

hours in a 24 hour period, the authority

having jurisdiction shall be notified, and the

building shall be evacuated or an approved

fire watch shall be provided for all parties left

unprotected by the shutdown until the fire

alarm system has been returned to service.

9.6.1.6

K 0346

Bldg. 01

Based on record review and interview,

the facility failed to provide a complete

written plan containing procedures to be

followed in the event the fire alarm

system has to be placed out of service for

4 hours or more in a 24 hour period. This


staff, and visitors.

Findings include:

Based on review of "Fire Watch -

Incident Action Plan" documentation

K 0346 1. The center's policy for interim

life safety measures (LSC 8.00)

includes detailed instructions for

providing notice to the local fire

department and the Indiana State

Department of Health whenever

the fire alarm or automatic

sprinkler system is out of service

for more than 4 hours in a 24

hour period. The policy includes

a requirement for notification to

the Indiana State Departement of

Health if either system is out of

service for 4 hours or more in a

24 hour period.

2. The clinical manager has been

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with the Clinical Manager during record

review from 9:50 a.m. to 1:30 p.m. on

05/15/17, the facility's written policy in

the event the fire alarm system is out of

service for four hours or more in a twenty

four hour period did not include

notification of the Indiana State

Department of Health (ISDH) which is an

authority having jurisdiction. Based on

interview at the time of record review,

the Clinical Manager stated additional

written fire watch policy documentation

was not available for review and

acknowledged the facility's written policy

in the event the fire alarm system is out

of service for four hours or more in a

twenty four hour period did not include

notification of ISDH.

provided an in-service on the

center policy for interim life safety

measures. The clinical manager

has also performed an inservice

for the center's staff on the policy.

3. The administrator is

responsible to ensure that all staff

are knowledgeable about the

center's policy regarding interim

life safety measures.



exhibit 4.

NFPA 101

Sprinkler System - Installation

Sprinkler System - Installation

Sprinkler systems (if installed) are installed

per NFPA 13.

Where more than two sprinklers are

installed in a single area for protection,

waterflow devices shall be provided to sound

the building fire alarm system or to notify a

constantly attended location such as a PBX,

security office, or emergency room.

20.3.5.1, 20.3.5.2, 21.3.5.1, 21.3.5.2,

9.7.1.2, 9.7, NFPA 13

K 0351

Bldg. 01





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facility failed to maintain 2 of over 50

automatic sprinklers in accordance with

NFPA 13, Standard for the Installation of

Sprinkler Systems. NFPA 13, 2010

edition, Section 6.2.7.1 states plates,

escutcheons, or other devices used to

cover the annular space around a

sprinkler shall be metallic, or shall be

listed for use around a sprinkler.

Escutcheons used with recessed,

flush-type, or concealed sprinklers shall

be part of a listed sprinkler assembly.

Cover plates used with concealed

sprinklers shall be part of the listed

sprinkler assembly. This deficient

practice could affect two staff.

Findings include:



1:30 p.m. to 3:00 p.m. on 05/15/17, two

recessed sprinkler locations in the

overflow supply room were missing their

cover plates. Based on interview at the

time of the observations, the Clinical

Manager acknowledged the

aforementioned recessed sprinkler

locations were missing their cover plates.

K 0351 1. Cover plates will be added to

the two sprinkler heads in the

overflow supply room. The rest

of the center has been toured to

ensure that all sprinkler heads are

in place.

2. The center's Monthly

PM checklist has been updated to

include a visual verification of

sprinkler heads throughout the

premise.



environmental rounding occurs on

a regular basis.


Checklist is attached as exhibit

1. Statement of work for adding

the cover plates is attached as

exhibit 16.

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NFPA 101 K 0353





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Sprinkler System - Maintenance and Testing

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

Bldg. 01

1. Based on record review, observation

and interview; the facility failed to ensure

2 of 2 private fire hydrants was

continuously maintained in reliable

operating condition and inspected and

tested periodically. NFPA 25, 2011

Edition, the Standard for the Inspection,

Testing, and Maintenance of

Water-Based Fire Protection Systems,

Table 7.1.1.2 requires wet and dry barrel

hydrants to be inspected annually and

after each operation. This deficient

practice affects all patients, staff and

visitors.

Findings include:

Based on review of Tyco

K 0353 1. The center's contracted fire

system service provider will

complete the following:

a.) Annual flow testing

for the single private fire hydrant

on the premises. The testing

documentation will include the

location and flow test results

for the single private hydrant on

the premises. Note there are two

private hydrants listed in the

inspection report.

b.) Quarterly sprinkler

system testing and waterflow

alarm testing.

c.) Verification of the number

and type of spare sprinkler heads

available in the center.

Building management and the

center's safety officer are

responsible to ensure that gauges

on the wet pipe sprinkler system

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SimplexGrinnell "Report of Inspection"

documentation dated 05/07/16 with the


from 9:50 a.m. to 1:30 p.m. on 05/15/17,

facility fire hydrants were stated as being

flow tested but documentation of the

location of each fire hydrant and the

results of the flow tests was not available

for review. Based on observations with

the Clinical Manager during a tour of the

facility from 1:30 p.m. to 3:00 p.m. on

05/15/17, the facility had two private fire

hydrants located at the northeast and

northwest side of the building. Based on

interview at the time of record review

and of the observations, the Clinical

Manager acknowledged documentation

of the location of each fire hydrant and

the results of the flow tests was not

available for review.


and interview; the facility failed to

provide written documentation or other

evidence the sprinkler system

components had been inspected and

tested for 3 of 4 quarters. LSC 4.6.12.1

requires any device, equipment or system

required for compliance with this Code

be maintained in accordance with

applicable NFPA requirements.

Sprinkler systems shall be properly

maintained in accordance with NFPA 25,

Standard for the Inspection, Testing, and

are inspected monthly and the the

pressure is recorded. Building

management and the center's

safety officer are responsible to

ensure that sprinkler pipe is not

used to support any non system

components.

2. The center's equipment list

and preventative maintenance sc

hedule checklist includes a

verification of Fire Hydrant

testing, Wet sprinkler gauge

testing, sprinkler system

testing and a spare sprinkler head

inspection.



documentation of all required

testing is onsite and available

upon request. The clinical

manager is responsible to ensure

that the center's equipment list

and preventative maintenance

checklist is updated monthly.

The center's monthly equipment

list and preventative maintenance

schedule is attached as exhibit 3.


checklist is attached as exhibit 1.

Results of fire system testing is

attached as exhibit 22.





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Maintenance of Water-Based Fire

Protection Systems. NFPA 25, 4.3.1

requires records shall be made for all

inspections, tests, and maintenance of the

system components and shall be made

available to the authority having

jurisdiction upon request. 4.3.2 requires

that records shall indicate the procedure

performed (e.g., inspection, test, or

maintenance), the organization that

performed the work, the results, and the

date. NFPA 25, 5.2.5 requires that

waterflow alarm devices shall be

inspected quarterly to verify they are free

of physical damage. NFPA 25, 5.3.3.1

requires the mechanical waterflow alarm

devices including, but not limited to,

water motor gongs, shall be tested

quarterly. 5.3.3.2 requires vane-type and

pressure switch-type waterflow alarm

devices shall be tested semiannually.

This deficient practice could affect all

patients, staff, and visitors in the facility.

Findings include:

Based on review of Tyco

SimplexGrinnell "Report of Inspection"



from 9:50 a.m. to 1:30 p.m. on 05/15/17,

documentation of quarterly sprinkler

system inspection for the third quarter

(July, August, September) and fourth





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quarter (October, November, December)

2016 was not available for review. In

addition, documentation of quarterly

sprinkler system inspection for the first

quarter (January, February, March) 2016

was not available for review. Based on

observations with the Clinical Manager

during a tour of the facility from 1:30

p.m. to 3:00 p.m. on 05/15/17, hanging

tags affixed to the sprinkler system risers

in the basement only documents annual

waterflow alarm inspection and testing

with the most recent being performed by

Tyco SimplexGrinnell in May 2016.

Based on interview at the time of record

review and of the observations, the

Clinical Manager acknowledged

waterflow alarm inspection and testing

for the aforementioned quarters was not

available for review.


and interview; the facility failed to

document sprinkler system gauge

inspections in accordance with NFPA 25.

NFPA 25, Standard for the Inspection,

Testing, and Maintenance of


2011 Edition, Section 5.2.4.1 states

gauges on wet pipe sprinkler systems

shall be inspected monthly to ensure that

they are in good condition and that

normal water supply pressure is being

maintained. Section 5.1.2 states valves





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and fire department connections shall be

inspected, tested, and maintained in

accordance with Chapter 13. Section

13.1.1.2 states Table 13.1.1.2 shall be

utilized for inspection, testing and

maintenance of valves, valve components

and trim. Section 4.3.1 states records

shall be made for all inspections, tests,

and maintenance of the system and its

components and shall be made available

to the authority having jurisdiction upon

request. This deficient practice could

affect all patients, staff, and visitors in

the facility.

Findings include:

Based on review of "MSCC Sprinkler

Check List" documentation with the


from 9:50 a.m. to 1:30 p.m. on 05/15/17,

monthly wet sprinkler system gauge

inspection documentation for the most

recent 12 month period was not available

for review. Based on telephone interview

with the Building Maintenance Manager

at the time of record review, the

aforementioned documentation pertained

to sprinkler system valve and seal checks

not sprinkler system gauge inspections.



1:30 p.m. to 3:00 p.m. on 05/15/17, the

facility has a supervised wet sprinkler





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system and had two pressure gauges.


the facility failed to ensure the supply of

spare sprinklers maintained on the

premises corresponded to the types and

temperature ratings of the sprinklers in

the property. NFPA 25, Standard for the

Inspection, Testing, and Maintenance of


2011 Edition, Section 5.4.1.4 states a

supply of spare sprinklers (never fewer

than six) shall be maintained on the

premises so that any sprinklers that have

operated or been damaged in any way can

be promptly replaced. The sprinklers

shall correspond to the types and

temperature ratings of the sprinklers in

the property. The sprinklers shall be kept

in a cabinet located where the

temperature in which they are subjected

will at no time exceed 100 degrees

Fahrenheit. This deficient practice could

affect all patients, staff, and visitors in

the facility.

Findings include:



1:30 p.m. to 3:00 p.m. on 05/15/17, one

sidewall sprinkler was observed installed

in the piped gas room in the basement.

No sidewall spare sprinklers were noted





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in the spare sprinkler cabinet at the

sprinkler system risers in the basement or

on the premises. Based on interview at

the time of the observations, the Clinical

Manager acknowledged no sidewall spare

sprinklers were in the spare sprinkler

cabinet or on the premises.


the facility failed to maintain 1 of 1

sprinkler systems in accordance with

NFPA 25. NFPA 25, Standard for the

Inspection, Testing, and Maintenance of


2011 edition, Section 5.2.2.2 states

sprinkler piping shall not be subjected to

external loads by materials either resting

on the pipe or hung from the pipe. This

deficient practice could affect three

patients, staff and visitors in the vicinity

of the entrance lobby.

Findings include:



1:30 p.m. to 3:00 p.m. on 05/15/17, one

blue cable was wrapped around a three

inch section of sprinkler pipe above the

suspended ceiling in the entrance lobby

for the facility near the vending

machines. Based on interview at the time

of the observations, the Clinical Manager

acknowledged the aforementioned





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sprinkler pipe location was used to

support non-system components.

NFPA 101

Sprinkler System - Out of Service

Sprinkler System - Out of Service

Where the sprinkler system is impaired, the

extent and duration of the impairment has

been determined, areas or buildings

involved are inspected and risks are

determined, recommendations are

submitted to management or designated

representative, and the fire department and

other authorities having jurisdiction have

been notified. Where the sprinkler system is

out of service for more than 10 hours in a 24

hour period, the building or portion of the

building affected are evacuated or an

approved fire watch is provided until the

sprinkler system has been returned to

service.

9.7.5, 15.5.2 (NFPA 25)

K 0354

Bldg. 01


the facility failed to provide a complete

written policy for 1 of 1 written fire

safety plans for the protection of

residents indicating procedures to be

followed in the event the automatic

sprinkler system has to be placed

out-of-service for 10 hours or more in a

24-hour period in accordance with LSC

K 0354 1. The center's policy for interim

life safety measures (LSC 8.00)

provides detailed instructions for

sprinkler impairment

procedures whenever the

automatic sprinkler system is out

of service for more than 4 hours

in a 24 hour period. The policy

requires notification to the Indiana

State Department of Health, the

center's insurance carrier and the

06/05/2017 12:00:00AM





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Section 9.7.5. LSC 9.7.5 requires

sprinkler impairment procedures comply

with NFPA 25, Standard for the

Inspection, Testing and Maintenance of

Water-Based Fire Protection Systems.

NFPA 25, 2011 Edition, Section 15.5.2

requires the fire department, insurance

carrier, the alarm company, the property

owner or designated representative and

other authorities having jurisdiction be

notified. This deficient practice could

affect all patients, staff and visitors.

Findings include:

Based on review of "Fire Watch -

Incident Action Plan" documentation

with the Clinical Manager during record


05/15/17, the written fire watch policy for

automatic sprinkler system impairment

did not include notification of the

insurance carrier, the alarm monitoring

company and the Indiana State

Department of Health (ISDH) which is an

authority having jurisdiction. Based on


the Clinical Manager stated additional

written fire watch policy documentation

was not available for review and

acknowledged the facility's written policy

in the event the automatic sprinkler

system is out of service for ten hours or

more in a twenty four hour period did not

alarm monitoring company.

2. The clinical manager has been

provided an in-service on the

center policy for interim life safety

measures. The clinical manager

has also performed an inservice

for the center's staff on the policy.

3. The administrator is

responsible to ensure that all staff

are knowledgeable about the

center's policy regarding interim

life safety measures.



exhibit 4.





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include notification of ISDH, the

insurance carrier and the alarm

monitoring company.

NFPA 101

Portable Fire Extinguishers

Portable Fire Extinguishers

Portable fire extinguishers are selected,

installed, inspected, and maintained in

accordance with NFPA 10, Standard for

Portable Fire Extinguishers.

20.3.5.3, 21.3.5.3, 9.7.4.1, NFPA 10

K 0355

Bldg. 01


the facility failed to ensure 2 of 8

portable fire extinguishers had

documented annual maintenance in

accordance with NFPA 10. NFPA 10,

2010 Edition, Section 7.3.1.1.1 states fire

extinguishers shall be subject to

maintenance at intervals of not more than

one year, at the time of hydrostatic test,

or when specifically indicated by an

inspection or electronic notification.

Section 7.3.3 states each fire extinguisher

shall have a tag or label securely attached

that indicates the month and year the

maintenance was performed, identifies

the person performing the work, and

identifies the name of the agency

performing the work. This deficient


visitors.

K 0355 1. Fire extinguisher inspections

are required monthly in the

center. The center's safety officer

has verified that all extinguishers

are up to date on their

inspections. The center's

contracted service provider has

performed annual maintenance

on all fire extinguishers on the

premise.

2. The center's life safety officer

will inspect all fire extinguishers

monthly and document those

inspections on the center's

Equipment List and Preventative

Maintenance checklist.

Verification of annual

maintenance has been added to

the center's equipment list and

PM schedule.



environmental walkthroughs are

completed monthly and

documentation of annual

maintenance is maintained

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Findings include:



1:30 p.m. to 3:00 p.m. on 05/15/17, the

ABC type portable fire extinguisher

located in the basement by the sprinkler

system risers had an affixed tag

indicating the most recent annual

maintenance was performed in April

2016. In addition, the ABC type portable

fire extinguisher located in the elevator

machine room on the first floor had an

affixed tag indicating the most recent

annual maintenance was performed in

June 2015. Based on interview at the

time of the observations, the Clinical

Manager stated SimplexGrinnell

performed annual maintenance for

facility fire extinguishers in April 2017

but acknowledged the aforementioned

two portable fire extinguishers did not

have annual maintenance documented

within the most recent twelve month

period.

3-1.19(b)



portable fire extinguishers located in the

facility were inspected at least monthly

and the inspections were documented

including the date and initials of the

onsite.





exhibit 3. Statement of work from

center's contracted service

provider on the fire extinguishers

is attached as exhibit 18.





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person performing the inspection in

accordance with NFPA 10. NFPA 10,

the Standard for Portable Fire

Extinguishers, 2010 Edition, Section

7.2.1.2 states fire extinguishers shall be

inspected either manually or by means of

an electronic monitoring device/system at

a minimum of 30-day intervals. Where

monthly manual inspections are

conducted, the date the manual inspection

was performed and the initials of the

person performing the inspection shall be

recorded. Where manual inspections are

conducted, records for manual

inspections shall be kept on a tag or label

attached to the fire extinguisher, on an

inspection checklist maintained on file,

or by an electronic method. Records

shall be kept to demonstrate that at least

the last 12 monthly inspections have been

performed. This deficient practice could

affect two staff and visitors.

Findings include:

Based on observation with the Clinical


1:30 p.m. to 3:00 p.m. on 05/15/17, the

ABC type portable fire extinguisher

located in the elevator machine room on

the first floor had an affixed tag lacking

monthly inspections after October 2016.

Based on interview at the time of

observation, the Clinical Manager stated





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no other documentation of monthly fire

extinguisher inspections was available for

review and acknowledged documentation

of monthly inspections for the portable

fire extinguisher located in the elevator

machine room after October 2016 was

not available for review.

NFPA 101

Utilities - Gas and Electric

Utilities - Gas and Electric

Equipment using gas or related gas piping

complies with NFPA 54, National Fuel Gas

Code, electrical wiring and equipment

complies with NFPA 70, National Electric

Code. Existing installations can continue in

service provided no hazard to life.

20.5.1, 21.5.1, 21.5.1.2, 9.1.1, 9.1.2

K 0511

Bldg. 01


facility failed to ensure electrical wiring

for 1 of 1 basement electrical fixtures

was maintained in safe operating

condition. LSC 21.5.1.1 requires utilities

comply with Section 9.1. LSC 9.1.2

requires electrical wiring and equipment

to comply with NFPA 70, National

Electrical Code. NFPA 70, 2011 Edition,

Article 300.15 states a box or conduit

body shall be installed at each junction

point unless otherwise permitted by

300.15(A) through (I). Article 314.28

states boxes and conduit bodies used as

pull or junction boxes shall be comply

K 0511 1. The building maintenance

provider has inspected the

basement area for any exposed

wiring and made corrections to

ensure that all connections are

contained in a junction box or

conduit body.

2. The facility safety officer shall

observe for any spliced or

exposed electrical wiring during

environmental walk throughs.

Any issues will be reported to

facilities maintenance for

immediate action. Exposed wiring

has been added to the center's

monthly PM checklist.




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with 314.28 (A) through (E). This

deficient practice could affect three

patients.

Findings include:



1:30 p.m. to 3:00 p.m. on 05/15/17,

spliced and exposed electrical wiring was

noted for an electrical fixture in the

basement above the entry door to the

basement. Based on interview at the time

of the observations, the Clinical Manager

acknowledged exposed electrical wiring

in the basement was not contained within

a junction box or conduit body.

completed at regular intervals and

that any issues are reported to

facilities maintenance in writing.



NFPA 101

Fire Drills

Fire Drills

Fire drills include the transmission of a fire

alarm signal and simulation of emergency

fire conditions. Fire drills are held at

unexpected times under varying conditions,

at least quarterly on each shift. The staff is

familiar with procedures and is aware that

drills are part of established routine.

Responsibility for planning and conducting

drills is assigned only to competent persons

who are qualified to exercise leadership.

Where drills are conducted between 9:00

PM and 6:00 AM, a coded announcement

K 0712

Bldg. 01





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may be used instead of audible alarms.

20.7.1.4 through 20.7.14.7


the facility failed to document activation

of the fire alarm system for first shift fire

drills conducted between 6:00 a.m. and

9:00 p.m. for 1 of 4 quarters. LSC

21.7.1.4 states fire drills in health care

occupancies shall include the

transmission of the fire alarm signal and

simulation of emergency fire conditions.

When drills are conducted between 9:00

p.m. (2100 hours) and 6:00 a.m. (0600

hours), a coded announcement shall be

permitted to be used instead of audible

alarms. This deficient practice could

affect all patients, staff and visitors in the

facility.

Findings include:

Based on review of "Code Red Drill

Evaluation Report" documentation with

the Clinical Manager during record


05/15/17, documentation for the first

shift fire drill conducted on 08/14/16 at

6:00 p.m. indicated the drill was

conducted after 6:00 a.m. but before 9:00

p.m. and did not include activation of the

fire alarm system and transmission of the

fire alarm signal. The aforementioned

first shift fire drill documentation stated

"Alarm not activated." Based on

K 0712 1. Center policy FP 8.00 Fire

Response requires quarterly fire

drills for all shifts. It further

outlines that the drills must

include the transmission of a fire

alarm signal and simulation of

emergency fire conditions.

Documentation is required for

each drill including staff

participation. The clinical

manager has held drills for both

shifts that include signal

transmission and emergency

simulation.

2. The center's safety officer is


quarterly fire drills are held in the

center. Those drills will include

the transmission of a alarm signal

and simulation of emergency

conditions. Documentation of

the required drills will be verified

and recorded on the center's

environmental compliance

checklist.


responsible to ensure that fire

drills are performed at required

intervals and that they follow

center policy.



exhibit 3. Policy FP 8.00 is

attached as exhibit 9.00.

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the Clinical Manager acknowledged

documentation for the first shift fire drill

conducted after 6:00 a.m. but before 9:00

p.m. did not include activation of the fire

alarm system and transmission of the fire

alarm signal.

NFPA 101

Gas and Vacuum Piped Systems - Warning

System

Gas and Vacuum Piped Systems - Warning

Systems

All master, area, and local alarm systems

used for medical gas and vacuum systems

comply with appropriate Category warning

system requirements, as applicable.

5.1.9, 5.2.9, 5.3.6.2.2 (NFPA 99)

K 0904

Bldg. 01

Based on record review, observation and

interview; the facility failed to install and

maintain the facility's piped gas and

vacuum systems in accordance with

NFPA 99. NFPA 99, Health Care

Facilities Code, 2012 Edition, Section

5.1.9.2 states a master alarm shall be

provided to monitor the operation and

condition of the source of supply, the

K 0904 1. The center has contracted with

their medical gas

systems provider to add a second

master alarm panel to the center.

2. Verification of the presence

and operation of the center's two

medical gas alarm panels will be

included on the center's monthly

PM checklist.



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reserve source (if any), and the pressure

in the main lines of each medical gas and

vacuum piping system. Section 5.1.9.2.1

states the master alarm system shall

consist of two or more alarm panels

located in at least two separate locations,

as follows:

(1) One master alarm panel shall be

located in the office or work space of the

on-site individual responsible for the

maintenance of the medical gas and

vacuum piping systems.

(2) In order to ensure continuous

surveillance of the medical gas and

vacuum systems while the facility is in

operation, the second master alarm panel

shall be located in an area of continuous

observation (e.g., the telephone

switchboard, security office, or other

continuously staffed located).

Section 5.1.9.4 states computer systems

used as substitute master alarms as

required by 5.1.9.2.1(2) shall have the

mechanical and electrical characteristics

described in 5.1.9.4.1 and the

programming characteristics described in

5.1.9.4.2. This deficient practice could


Findings include:

Based on review of Artec Environmental

Monitoring's "Master Warning Alarms -

Mechanism in Disrepair" section of


completed in the center at routine

intervals.



Contractor statement of work for

second alarm panel is attached

as exhibit 20.





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"Medical Gas PM Inspection

(Addendum)" documentation dated

02/29/16 with the Clinical Manager

during record review from 9:50 a.m. to

1:30 p.m. on 05/15/17, the Medical

Oxygen Manifold System, the Medical

Vacuum System and the Nitrogen

Manifold "has one master alarm (2 are

required)." Based on interview at the

time of record review, the Clinical

Manager stated the facility has not

installed a second master alarm location,

does not utilize computer systems for

substitute master alarms and

acknowledged the facility has only one

master alarm location for piped gas and

vacuum systems. Based on observations

with the Clinical Manager during a tour

of the facility from 1:30 p.m. to 3:00 p.m.

on 05/15/17, the facility has one master

alarm location for piped gas and vacuum

systems in the Post Op area of the

facility.

NFPA 101

Gas and Vacuum Piped Systems -

Maintenance Pr

Gas and Vacuum Piped Systems -

K 0907

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Maintenance Program

Medical gas, vacuum, WAGD, or support

gas systems have documented maintenance

programs. The program includes an

inventory of all source systems, control

valves, alarms, manufactured assemblies,

and outlets. Inspection and maintenance

schedules are established through risk

assessment considering manufacturer

recommendations. Inspection procedures

and testing methods are established through

risk assessment. Persons maintaining

systems are qualified as demonstrated by

training and certification or credentialing to

the requirements of AASE 6030 or 6040.

5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14,

5.3.13.4.2 (NFPA 99)


the facility failed to maintain the facility's

piped gas and vacuum systems in

accordance with NFPA 99, Health Care

Facilities Code, 2012 Edition. This


staff and visitors.

Findings include:

Based on review of Artec Environmental

Monitoring's "Medical Vacuum System"

section of "Medical Gas PM Inspection"



from 9:50 a.m. to 1:30 p.m. on 05/15/17,

the medical-surgical vacuum receiver(s),

pressure-sensing devices, mainline

pressure gauges and alarm indicators

were listed as "Fail" as the result of the

K 0907 1. The center's contracted service

provider will performed complete

tests of the vacuum system.

Those tests will include receivers,

pressure sensing devices,

mainline pressure gauges and

alarm indicators. Zone valves,

master alarm signal activation

and vacuum lag will be verified in

good working order. The results

of that testing will be maintained

onsite and any needed repairs will

be performed.

2. Annual testing will be

verified via the

center's equipment list and

preventative maintenance

checklist.


responsible to ensure that annual

testing occurs for the center's

medical gas and vacuum

systems.



06/26/2017 12:00:00AM





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PM inspection. The "Zone Valves"

section of the aforementioned PM

Inspection stated the zone valves were

located in the same room as the outlets

served for vacuum systems and oxygen

and were also listed as "Fail." In

addition, the "Comments" section of the

"Master Alarm Signal Activation" section

of the aforementioned report stated "No

Vacuum Lag Present At Master Panel."

Based on interview at the time of record

review, the Clinical Manager stated piped

gas and vacuum systems repair or

replacement on or after 02/29/16 has not

been performed and acknowledged

documentation of piped gas and vacuum

systems repair or replacement on or after

02/29/16 was not available for review.

exhibit 3. Statement of work for

Medical Gas/Vacuum pump

contractor attached as exhibit 20.

NFPA 101

Electrical Systems - Other

Electrical Systems - Other

List in the REMARKS section, any NFPA 99

Chapter 6 Electrical Systems requirements

that are not addressed by the provided

K-Tags, but are deficient. This information,

along with the applicable Life Safety Code or

K 0911

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NFPA standard citation, should be included

on Form CMS-2567.

Chapter 6 (NFPA 99)


facility failed to ensure access and

working space was maintained for 3 of

over 5 electrical panels. NFPA 99,

Health Care Facilities Code, 2012

Edition, Section 6.3.2.1 states electrical

installation shall be in accordance with

NFPA 70, National Electric Code. NFPA

70, 2011 Edition, Article 110.26 states

access and working space shall be

provided and maintained about all

electrical equipment to permit ready and

safe operation and maintenance of such

equipment. Working space for

equipment operating at 600 volts,

nominal, or less and likely to require

examination, adjustment, servicing, or

maintenance while energized shall

comply with the dimensions of 110.26(A)

(1), (2) and (3). 110.26(A)(1) states the

depth of the working space in the

direction of live parts shall not be less

than that specified in Table 110.26(A)(1)

which the minimum clear distance is 3

feet. 110.26(A)(2) states the width of the

working space in front of the electrical

equipment shall be the width of the

equipment or 762 mm (30 in.), whichever

is greater. In all cases, the work space

shall permit at least a 90 degree opening

of equipment doors or hinged panels.

K 0911 1. The facility manager has

performed a walkthrough of the

facility. The nine doors propped

against the wall and stored 18

inches in front of the "Main

SWBD" electrical panel in the

basement electrical room have

been relocated. Any boxes

stored within one foot in front of

the "1E1A" and "IL3" electrical

panels have been relocated. . All

miscellaneous items were stored

on the floor underneath any

electrical panel have been

moved.

2. This deficiency will be

prevented by the performance of

environmental compliance

walkthroughs of the center.

Conditions will be verified at

regular intervals.




performed in the center.


Checklist is attached as exhibit

1. See statement of work

exhibit 17.

06/07/2017 12:00:00AM





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110.26(A)(3) states the work space shall

be clear and extend from the grade, floor,

or platform to a height of 6 1/2 feet or the

height of the equipment, whichever is

greater. Article 110.26(B) states the

working space required by this section

shall not be used for storage. This


staff and visitors.

Findings include:



1:30 p.m. to 3:00 p.m. on 05/15/17, the

following was noted:

a. nine doors were propped against the

wall and stored 18 inches in front of the

"Main SWBD" electrical panel in the

basement electrical room.

b. boxes were stored one foot in front of

the "1E1A" electrical panel in the first

floor electrical room by the elevator

machine room. Boxes were also stored

one foot in front of the "IL3" electrical

panel in the room. Miscellaneous items

were stored on the floor underneath each

electrical panel.

Based on interview at the time of the

observations, the Clinical Manager

acknowledged the miscellaneous items

were stored within the working space in

front of the three electrical panels.





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NFPA 101

Electrical Systems - Essential Electric Syste

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.

K 0918

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6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110,

NFPA 111, 700.10 (NFPA 70)



emergency generators was kept in

reliable operating mode in accordance

with NFPA 110, Standard for Emergency

and Standby Power Systems. NFPA 110,

2010 Edition, Section 8.3.1 states the

Emergency Power Supply Systems

(EPSS) shall be maintained to ensure that

the system is capable of supplying service

within the time specified for the type and

for the time duration specified for the

class. Section 8.3.7.2 states defective

batteries shall be replaced immediately

upon discovery of defects. This deficient


visitors.

Findings include:


Manager at 3:10 p.m. on 05/15/17, the

horn switch for the Generac Standby

Power Monitor remote annunciator

located at the nurse's station for the

facility's emergency generator was turned

to the off position. The "Low Water

Temp" trouble light was illuminated on

the annunciator panel. The annunciator

horn sounded when the horn switch was

turned to the on position two separate

times. Based on interview at time of the

K 0918 1. The center's contracted

service provider for generator

maintenance has performed all

required testing and

provided documentation

on transfer time for monthly load

tests and cool down time. The

annunciator panel including all

panel lights and the horn switch

have been tested and are

operating correctly. Center staff

have been in-serviced on how to

respond to warning lights and

alarms regarding the center's

emergency generator.

2. The center's safety officer

shall confirm monthly generator

testing on the center's equipment

list and preventative maintenance

schedule checklist. Any

deficiencies will be reported the

center's contracted service

provider.


responsible to ensure that facility

maintenance is performed at

specified intervals and the results

are made available upon request.



exhibit 3.

06/20/2017 12:00:00AM





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observations, the Clinical Manager stated

she was unaware of any issues with the

emergency generator, it started and ran

during the most recent load test but

acknowledged the aforementioned

annunciator trouble light was illuminated

with the annunciator horn silenced.

2. Based on record review and interview,

the facility failed to document the

transfer time to the alternate power

source on the monthly load tests for 5 of

the most recent 12 months to ensure the

alternate power supply was capable of

supplying service within 10 seconds.

NFPA 99, Health Care Facilities Code,

2012 Edition, Section 6.4.4.1.1.1 states

the generator set or other alternate power

source and associated equipment,

including all appurtenance parts shall be

so maintained as to be capable of

supplying service within the shortest time

frame practicable an within the 10 second

interval specified in 6.4.1.1.10 and

6.4.3.1. This deficient practice could


Findings include:

Based on review of "Emergency

Generator - Monthly Test Log"

documentation with the Clinical Manager


1:30 p.m. on 05/15/17, monthly load





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testing documentation for 01/10/17

through 05/06/17 did not include transfer

time from normal power to emergency

power. Based on interview at the time of

record review, the Clinical Manager

acknowledged monthly load testing

documentation for the aforementioned

period did not include transfer time from

normal power to emergency power.

3. Based on record review and interview,


emergency generators was allowed a 5

minute cool down period after a load test

for 5 of the most recent 12 months in

accordance with NFPA 110, Standard for

Emergency and Standby Power Systems.

NFPA 110, 2010 Edition, Section 6.2.10

Time Delay on Engine Shutdown

requires a minimum time delay of 5

minutes shall be provided for unloaded

running of the Emergency Power Supply

(EPS) prior to shutdown to allow for

engine cooldown. This time delay shall

not be required on small (15 kW or less)

air-cooled prime movers. NFPA 110,

Section 8.3.4 states a permanent record of

the Emergency Power Supply Systems

(EPSS) inspections, tests, exercising,

operation, and repairs shall be maintained

and readily available. This deficient


visitors.





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Findings include:

Based on review of "Emergency

Generator - Monthly Test Log"

documentation with the Clinical Manager


1:30 p.m. on 05/15/17, monthly load

testing documentation for 01/10/17

through 05/06/17 did not include did not

include cool down time. Based on


the Clinical Manager stated the

emergency generator is load tested

monthly for at least 30 minutes but

acknowledged cool down time is not

specifically recorded in monthly load

testing documentation for the

aforementioned five month period.

NFPA 101

Gas Equipment - Cylinder and Container

Storag

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

K 0923

Bldg. 01





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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)


facility failed to ensure 1 of 1 piped gas

system supply areas was enclosed with a

separation of 1 hour fire resistive

construction. NFPA 99, Health Care

Facilities Code, 2012 Edition, Section

11.3.1 states storage for nonflammable

gases equal to or greater than 3000 cubic

feet at STP shall comply with 5.1.3.3.2

and 5.1.3.3.3. Section 5.1.3.3.2(4) states

K 0923 1. Building maintenance has

corrected the latching

mechanisms on the east door

serving as entry to the medical

gas room.

2. Confirmation that door latching

mechanisms are functioning has

been added to the

center's monthly PM checklist.


responsible for environmental

rounding at regular intervals.

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central supply systems, if indoors, shall

be constructed and use interior finishes of

noncombustible or limited combustible

materials such that all walls, floors,

ceilings, and doors are of a minimum

1-hour fire resistance rating. This

deficient practice could affect all patients

and staff.

Findings include:



1:30 p.m. to 3:00 p.m. on 05/15/17, the

piped gas system supply room in the

basement has two separate door sets

serving as the entry doors to the room.

The east door in the northeast door set

failed to latch into the door frame as the

latching mechanism at the top of the door

failed to protrude into the door frame.

Fourteen 'H' type oxygen cylinders were

observed stored in the room. Based on

interview at the time of the observations,

the Clinical Manager acknowledged the

aforementioned entry door to the piped

gas supply room would not latch into the

door frame and did not provide the room

with one hour fire resistive construction.







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