Beacon Hospice of Austin

“The facility failed to comply with life safety requirements for Chapter 18, New Healthcare Occupancies: NOTE: The below noted examples are not intended to be an all-inclusive list. All requirements of NFPA 101 (2012 Edition) must be met. Findings include, but are not limited to: (A) Building Construction V(111): Reference NFPA 101 Section 18.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 18.1.6.2 (See 8.2.1.) and NFPA 220, 2012 Edition Section 4.6 Type V (111) Construction. Type V (111) construction shall be that type in which structural elements, walls, arches, floors, and roofs are entirely or partially of wood or other approved material. 1. Walls and columns supporting loads: a. The facility failed to provide 1-hour fire resistive construction for walls supporting beams (point loads) for the LVL structural beams supporting the Cupola above Entry Lobby ceiling. Record review of Foundation Plan – Building #1 on sheet S1-1, dated 8/22/22, and Roof Framing Plan – Building #1 on sheet S1-3, dated 8/22/22, shows a key note, “;F-2 inside an oval,” for designating interior load bearing walls. Exterior walls are otherwise load bearing. Fire resistance requirements for supporting point loads on load bearing walls was not found on drawings. Supporting vertical structural elements, such as columns or stud packs, to carry the load beams supporting the cupola were not shown on the foundation plan on Foundation Plan – Building #1 on sheet S1-1. b. The port cochere structural supports (2) were constructed of bundled 2 x dimensional lumber (stud-packs) that support beams in two directions. The stud-packs were constructed as “;wall framing” and wrapped with OSB sheathing with manufactured stone veneer and cement plaster (stucco) on the exterior. They supported a 24 x 25 port cochere. In a phone interview on September 17, 2024 at 9:00 to10:00 AM, with the structural engineer, they said these stud packs were acting as supporting columns. c. The ambulance entry porch had a structural column support constructed of bundled 2 x 6 dimensional lumber (stud-packs) that supported beams in two directions The stud-packs were constructed of wall framing and wrapped with OSB sheathing that had manufactured stone veneer and EFIS / cement plaster (stucco) on the exterior. The covered ambulance porch measured approximately 14-2” x 13. d. The cupola support framing was constructed of bundled 2 x dimensional lumber (stud-packs) that acted as a columns transferring the cupola and associated roof load (LVL beams at roof) to LVL beams above Entry Lobby ceiling. Record review of S3-3 titled “;Framing Details” dated 8/22/22, revealed the cupola was field framed by 2 x dimensional lumber, LVLs, and 2 x 8 dimensional lumber beams. None of these structural members were protected to meet Type V(III) construction requirements. 2. Structural Beams: a. Four (4) triple 2 x 8 structural beams on all sides of the Cupola located above the ceiling were carrying cupola walls and were not fire protected. The bearing point was above the ceiling plane. The beams were exposed and not fire protected with 2 layers of Type X gypsum board gypsum board in the attic. b. Three I ¾” x 11-1/4” LVL structural beams on both sides of the Cupola were carrying load from the roof. The bearing point was above the ceiling plane. The beams were not protected with 2 layers of Type X gypsum board. Structural beams, must be protected to the bearing point to meet Type V(III) building construction. c. Fire protection of the dropped beams supporting port cochere (3 sides) and those supporting roof at ambulance porch (2 sides) could not be verified. The beams extended below the roof-ceiling assembly and were not protected by the roof-ceiling assembly. Record review of S3-3 titled “;Framing Details,” dated 8/22/22, called for (3) I ¾” x 11-1/4” LVL (LO Beam) to be rated wrap with 5/8” Type X Gypsum Board on both sides and bottom, with a note to see Architectural drawings for additional notes. HHS will accept two-layers of 5/8” thick Type-X gypsum board on all sides of a structural beams as equivalent to 1-hour fire-resistive protection for beams. 4. Fire Rated Roof/Ceiling Assemblies: The facility failed to either utilize a tested 1-hour fire-resistance rated roof/ceiling assembly, or to provide a tested 1-hour fire-resistance rated roof/ceiling assembly that matched the installed condition at the following locations: a. Portions of the Entry Lobby ceiling (below cupola) were constructed with dimensional lumber with unequal spacing supported by joist hangers and toe-nailing into beams supporting the cupola. Metal furring channels were attached to the ceiling framing perpendicular and one layer of 5/8” Type C gypsum board was fastened to the underside of the channels. b. The low slope roof mechanical roof/ceiling deck was constructed with 2 x 10 wood joists at 16 inches on center with one layer of 5/8” Type C gypsum board fastened to metal channels on the underside of the structure. c. The cupola interior side walls (vertical and angled) were constructed of 2 layers of 5/8” thick Type-X gypsum board installed directly on wood framing UL P522 has not been tested for oriented vertically applications of gypsum board. d. Truss forming the roof / ceiling assembly of the corridor in the patient area had one layer of 5/8” gypsum board installed on resilient metal channels applied to the vertical members of the trusses to form the upper portion (above ceiling) of the finished corridor wall. UL P-522 has not been tested for fire resistance with a vertical application of gypsum board. The contractor stated that they continued the roof-ceiling assembly on the vertical members of the trusses using the same Type C gypsum board used for the rest of the ceiling assembly. None of these conditions match UL Design No. P522. Record review on 09/11/2024 revealed that the Construction Documents called for “;UL Design No. P 522” for the ceiling assembly below the Cupola. Refer to detail 2, Building Section, on Sheet A-5.2 dated 8/22/22 for the cupola/light well cross section. Refer to detail 1, Wall Section, and detail 2, Wall Section, on Sheet A-5.9, dated 8/22/22, for the low-slope mechanical roof section. Refer to Roof Framing Plan on S1-3, dated 8/22/22, for roof framing information. Refer to details S3-301 and S3-302, on Sheet S3-3, dated 8/22/22 for cupola cross sections. Record review on 09/11/2024 revealed that Construction Documents call for “;UL Design No. P 522” for roof-ceiling assembly. The structural elements of the mechanical roof deck were 2 x 10 wood joists at 16 inches on center and do not match UL Design No. P522. Record review of construction documents (architectural drawings) on 09/11/2024 revealed that Construction Documents call for 2 layers of 5/8” thick Type-X gypsum board to be applied on the walls of the Cupola (vertically oriented ceiling elements). (Refer to detail 2. Building Section, Sheet A-5.2, dated 8/22/22) Record review of UL Design No. P522 showed the designated tested roof-ceiling assembly should consist of one layer of Type C, ULIX, or IP-X2 gypsum board from selected manufacturers, on resilient channels spaced at 16 inches on center and at each gypsum panel end joint, on pitched or parallel chord wood trusses spaced a maximum of 24 inches on center. During an interview at 9:00-10:00 am on September 17, 2024 the structural engineer stated the walls of the oculus (i.e.the walls forming the opening below the cupola that extended from the primary ceiling plane to the roof plane) did not carry loads of the cupola structure above the roof. The cupola structure loads were carried by beams, columns (stud packs) in attic and walls below the ceiling. e. Penetrations in the fire rated roof-ceiling assembly: i. Recessed can lights penetrated the roof-ceiling assembly and they were not protected by a 1-hour fire-rated enclosure. The recessed can lights had job-built gypsum board enclosures (boxes) around them consisting of a single layer of gypsum board fastened together with screws and fire caulk. Gypsum board enclosures were not attached to wood framing. The enclosure boxes were attached to the gypsum board ceiling and metal channel tracks with intumescent fire caulk. Record review of the electrical cut sheets revealed the recessed can lights were not fire rated. Record review of the architectural drawings revealed no documentation of how to construct a 1-hour fire rated gypsum box enclosure. ii. Ceiling Radiation Dampers: Ceiling radiation dampers penetrating the ceiling, including two (2) in the laundry room, were not fitted in accordance with the manufacturers installation instructions for Pottorff models CFD-521, CFD-521-IP and CFD 521-NP. A 1” x 1” x 22 ga. retaining angle was not installed at the room side of the ceiling gypsum board. Not all duct penetrations at all locations were observed by the survey team. Exhaust fans were observed in bathrooms throughout the facility, negative pressure rooms, laundry and bio rooms, family shower, patient shower, and janitor closet. Record review of the Pottorff ceiling radiation dampers product information data revealed retaining angles are required at the room side of a duct penetration of the ceiling gypsum board. Record review revealed that documentation for exhaust fans was not available to confirm their compliance with the designated roof-ceiling assembly. References: NFPA 101, 2012 EditionChapter 18 New Health Care OccupanciesNEW Building construction type and stories meets Table 18.1.6.1, unless otherwise permitted by 18.1.6.2 through 18.1.6.7 18.1.6.4, 18.1.6.5 Chapter 8 Features of Fire Protection8.2.1 Construction8.2.1.2 NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification. NFPA 220, 2012 Edition5.1.2.3 Structural elements, such as girders, beams, trusses, and spandrels, that have direct connections to columns carrying gravity loads, and that are essential to the stability of the building as a whole, shall have a fire resistance rating not less than that of the columns to which they are connected.[5000:7.2.7.2.3] 5.1.4 Structural elements, other than those specified in 5.1.3, required to have a fire resistance rating shall be protected by individual encasement, or by membrane or ceiling protection in accordance with NFPA 5000, Building Construction and Safety Code, Section 8.6, or a combination of both. [5000:7.2.7.4] 5.1.5 In addition to the requirements of 5.1.3 and 5.1.4, columns shall meet the following requirements:(1) Where columns require a fire resistance rating, the entire column, including its connections to beams or girders, shall be individually protected.(2) Where the column extends through a ceiling, the fire resistive protection provided for the column shall be continuous from the top of the floor through the ceiling space to the top of the column.”

“Based on observation and interview, the facility failed to maintain the means of egress requirements in accordance with LSC sections 7.1.10.1 and 7.2.1.3.2 as referenced by LSC section 18.2.1. The facility failed to ensure that the means of egress from patient rooms was maintained free of obstructions to full use in case of an emergency. The facility failed to maintain a level floor surface on both sides of the East exit door for a distance not less than the width of the exit door. Findings include but are not limited to: (1) Observations on 9/10/2024 starting at 9:30 a.m. revealed that the doors to patient rooms had closers with magnetic hold-opens that would release with activation of the fire alarm or power loss. It was observed that when the ensuite bathroom door of a patient room was opened past 90 degrees, automatic closing of the patient room doors resulted in interlocking of the door handles of the patient room door and bathroom door, creating an impediment to the means of egress. (2) Observations on 9/11/2024 at 9:53 a.m. revealed that the sidewalk immediately outside of the East exit door (the exit discharge) had a slope in the direction of egress travel of 4 degrees, or expressed as a ratio, 1:14.301. Refer to LSC 7.2.1.3.1. In an interview with the GC on 9/11/2024, they stated they were not aware that the surface outside of the East exit door needed to be level since it was not an accessible exit (i.e., it did not need to comply with Texas Accessibility Standards) and has passed an accessibility review. References: NFPA 101, 2012 Edition,Chapter 18 New Health Care Occupancies18.2 Means of Egress Requirements.18.2.1 General. Every aisle, passageway, corridor, exit discharge,exit location, and access shall be in accordance with Chapter 7,unless otherwise modified by 18.2.2 through 18.2.11. Chapter 7 Means of Egress7.1.10 Means of Egress Reliability.7.1.10.1 General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 7.2 Means of Egress Components7.2.1.3 Floor Level.7.2.1.3.1 The elevation of the floor surfaces on both sides of a door opening shall not vary by more than 1⁄2 in. (13 mm), unless otherwise permitted by 7.2.1.3.5 or 7.2.1.3.6.7.2.1.3.2 The elevation of the floor surfaces required by 7.2.1.3.1 shall be maintained on both sides of the door openings for a distance not less than the width of the widest leaf.”

“Based on observation and interview, the facility failed to provide doors meeting the requirements of NFPA 101 sections 7.2.1.4.2 and 7.2.1.5.10.2, as referenced by section 18.2.2.2.1. The facility failed to provide door hardware in the means of egress that would release with not more than one releasing operation for 3 of 5 exit doors. The facility failed to provide doors swinging in the direction of egress travel for 1 interior corridor pair of doors serving an occupant load of greater than 50 people. Findings include, but are not limited to: Observations on 9/10/2024, at 10:30 a.m., revealed that the exit at the main entry and the exits located at the ends of the East and West corridors were each secured with a deadbolt lock and privacy lockset with a thumb-turn lock requiring pinching and twisting to operate. Operation of the deadbolt lock and privacy lock were not interconnected. Three motions were required to open the door: one to unlock the deadbolt, one to unlock the privacy lock, and one to operate the door handle. In an interview with the GC on 9/10/2024 at 10:30 am, they said they were aware that multiple motions were required to open the doors but thought a separate deadbolt lock and privacy lockset were acceptable on an egress door because he had installed them on exit doors in another hospice. Observations on 9/10/2024 at 10:00 am revealed that cross corridor doors leading from the front business area of the facility to the rear inpatient area of the facility were not opposite swinging. A record review of the construction documents on 9/17/2024 at 11:00 am revealed that rooms in the front business area were also designated as areas for families to gather. Occupant loads for these rooms are calculated as follows, based upon NFPA 101, Table 7.3.1.2, Occupant Load Factor. Chapel: Area: 262 square feet; Occupant Load Factor: 7 square foot per person; Occupant Load: 37 persons Dining: Area: 275 square feet; Occupant Load Factor: 15 square foot per person; Occupant Load: 18 persons Family Room: Area: 276 square feet; Occupant Load Factor: 15 square foot per person; Occupant Load: 18 persons Seating Areas open to Corridor:Area: 288 square feet; Occupant Load Factor: 15 square foot per person; Occupant Load: 19 persons Office areas:Area: 500+ square feet; Occupant Load Factor: 100 square foot per person; Occupant Load: 5 persons Total occupant load for front business area: 97 persons, and therefore the doors must swing in the direction of egress. References: NFPA 101, 2012 Edition,Chapter 18 New Health Care Occupancies18.2 Means of Egress Requirements.18.2.2 Means of Egress Components.18.2.2.1 Components Permitted. Components of means of egress shall be limited to the types described in 18.2.2.2 through 18.2.2.10.18.2.2.2 Doors.18.2.2.2.1 Doors complying with 7.2.1 shall be permitted. Chapter 7 Means of Egress7.2 Means of Egress Components7.2.1.4 Swing and Force to Open.7.2.1.4.2 Door Leaf Swing Direction. Door leaves required to be of the side-hinged or pivoted-swinging type shall swing in the direction of egress travel under any of the following conditions: (1) Where serving a room or area with an occupant load of 50 or more, except under any of the following conditions:(a) Door leaves in horizontal exits shall not be required to swing in the direction of egress travel where permitted by 7.2.4.3.8.1 or 7.2.4.3.8.2.(b) Door leaves in smoke barriers shall not be required to swing in the direction of egress travel in existing health care occupancies, as provided in Chapter 19.(2) Where the door assembly is used in an exit enclosure, unless the door opening serves an individual living unit that opens directly into an exit enclosure(3) Where the door opening serves a high hazard contents area 7.2.1.5 Locks, Latches, and Alarm Devices7.2.1.5.10.2 The releasing mechanism shall open the door leaf with not more than one releasing operation, unless otherwise specified in 7.2.1.5.10.3, 7.2.1.5.10.4, or 7.2.1.5.10.6.”

“Based on observation and interview, the facility failed to provide exit doors of at least 41.5 inches in clear width for 3 of 4 exit doors subject to patient use in accordance with sections 18.2.3.6 and 18.2.3.7 of the LSC. The facility failed to provide doors of at least 41.5 inches in clear width, or a pair of doors with a minimum 32-inch opening and automatic flush bolts, at the patient-use exit doors at the building main entry and East and West corridors. Findings include but are not limited to: On 9/11/2024 at 9:30 am, the exit doors at the ends of the East and West corridors were measured to be 35 inches in clear width. The exit door at the front entry was measured to be a pair of doors with two 36-inch leaves, providing 72 inches total opening width. The inactive leaf of the pair of doors had manual flush bolts to secure the door in place. In an interview with the GC on 9/11/2024 at 10:00 am, they stated that the doors at the ends of the East and West corridors were originally scheduled to be 4-foot doors but had been changed, with the approval of the architect, to 3-foot doors so that residential doors could be used for home-like aesthetics. He said that he was not aware that the pair of doors at the front entry or the exit doors at the ends of the corridors required a door larger than 3 feet. References:NFPA 101, 2012 EditionChapter 18 New Health Care Occupancies18.2.3.6 The minimum clear width for doors in the means of egress from sleeping rooms; diagnostic and treatment areas, such as x-ray, surgery, or physical therapy; and nursery rooms shall be as follows:(1) Hospitals and nursing homes — 41 1⁄2 in. (1055 mm)(2) Psychiatric hospitals and limited care facilities— 32 in. (810 mm)18.2.3.7 The requirements of 18.2.3.6 shall not apply where otherwise permitted by one of the following:(1) Doors that are located so as not to be subject to use by any health care occupant shall be not less than 32 in. (810 mm) in clear width.(2) Doors in exit stair enclosures shall be not less than 32 in. (810 mm) in clear width.(3) Doors serving newborn nurseries shall be not less than 32 in. (810 mm) in clear width.(4) Where a pair of doors is provided, all of the following criteria shall be met:(a) Not less than one of the doors shall provide not less than a 32 in. (810 mm) clear width opening.(b) A rabbet, bevel, or astragal shall be provided at the meeting edge.(c) The inactive door leaf shall have an automatic flush bolt to provide positive latching.”

“Based on observation, the facility failed to provide protection for the diesel storage tanks located at the generator in accordance with NFPA 30 section 22.15 as referenced by NFPA 101 18.3.2.1 and 8.7.3.1. Observations on 9/11/2024 at 9:00 a.m. revealed that the diesel storage tanks located under the emergency generator directly adjacent to the fire lane were not protected by an enclosure or bollards to prevent a vehicle collision. References: NFPA 101, 2012 Edition18.3.2 Protection from Hazards.18.3.2.1 Hazardous Areas. Any hazardous areas shall be protected in accordance with Section 8.7, and the areas described in Table 18.3.2.1 shall be protected as indicated. Chapter 8 Features of Fire Protection 8.7.3 Flammable Liquids and Gases.8.7.3.1 The storage and handling of flammable liquids or gases shall be in accordance with the following applicable standards:(1) NFPA 30, Flammable and Combustible Liquids Code(2) NFPA 54, National Fuel Gas Code(3) NFPA 58, Liquefied Petroleum Gas Code”

“Based on observation and interview, the facility failed to provide a ¾ hour fire-rated door and self-closing device at Mechanical Room, Rm 149, which contained two gas-fired water heaters. Findings include, but are not limited to: An observation and interview on 09/10/2024 at 10:00 a.m., revealed that the door to Room 149, Mechanical Room was labeled and rated for 20 minutes fire exposure. The door frame was labeled and rated for 1-hour. The door did not have a self-closing device. The Contractor acknowledged the correct door had been installed at another location and that the door needs a closer. References: NFPA 101, 2012 Edition18.3.2 Protection from Hazards.18.3.2.1 Hazardous Areas. Any hazardous areas shall be protected in accordance with Section 8.7, and the areas described in Table 18.3.2.1 shall be protected as indicated. Table 18.3.2.1 Hazardous Area Protection (Excerpt)Hazardous Area Description: Boiler and fuel-fired heater rooms Protection/Separation: 1 hour”

“Based on observation and interview, the facility failed to provide portable fire extinguishers in accordance with section 6.3.1 NFPA 10 as referenced by NFPA 101 sections 18.3.5.12 and 9.7.4.1. The facility failed to install a fire extinguisher meeting the requirements of NFPA 10 6.3.1.1 and 6.3.1.2 at the emergency generator. Observations on 9/11/2024 starting at 1:00 p.m. revealed that there was no portable fire extinguisher with a 40-B or 80-B rating within 30 or 50 feet, respectively, of the diesel generator. In an interview with the GC on 9/11/2024 at 1:00 p.m., he acknowledged that there was no portable fire extinguisher at the generator. References: NFPA 101, 2012 Edition Chapter 18 New Health Care Occupancies 18.3 Protection18.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1. Chapter 9 Building Service and Fire Protection Equipment 9.7.4 Manual Extinguishing Equipment. 9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10, 2012 Edition 6.3 Installations for Class B Hazards.6.3.1 Other Than for Fires in Flammable Liquids of Appreciable Depth.6.3.1.1 Minimum sizes of fire extinguishers for the listed grades of hazard shall be provided in accordance with Table 6.3.1.1, except as modified by 6.3.1.5.6.3.1.2 Fire extinguishers shall be located so that the maximum travel distances do not exceed those specified in Table 6.3.1.1. (See Annex E.) Table 6.3.1.1 Fire Extinguisher Size and Placement for Class B Hazards (Excerpt) Extra (high) 40-B 30 ft”

“Based on interview, the facility failed to provide fire protection at back-to-back installations of electrical outlets and medical gas outlet assemblies in the headwalls between patient rooms in the 1-hour rated smoke barrier wall. Findings include, but are not limited to: In an interview with the General Contractor, when asked to remove the electrical outlet covers in the smoke barrier walls for inspection, he stated that putty packs or other means of fire protection had not been installed at all back-to-back electrical outlets and patient room med-gas outlet assemblies located in the smoke barrier wall. He stated that he knew this needed to be fixed and there was no need to remove the covers for inspection. References: NFPA 101, 2012 EditionChapter 18 New Health Care Occupancies18.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1-hour fire resistance rating, unless otherwise permitted by one of the following:(1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:(a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c).(b) Not less than two separate smoke compartments shall be provided on each floor.(2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems. Chapter 8 Features of Fire Protection8.5 Smoke Barriers8.5.6 Penetrations8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.8.5.6.3 Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met.”

“Based on record review, observation and interview, the facility failed to meet the requirements of sections 6.3.1 and 6.7.1 of ASHRAE 170, as referenced by 42 CFR 418.110 and NFPA 99. The facility failed to provide fully ducted return or exhaust systems for patient care areas that would maintain required pressure relationships. The facility failed to provide the pressure relationships required by ASHRAE 170 Table 7-1. The facility failed to maintain 25 feet from all exhaust and vent discharges to outdoor air intakes. Findings include, but are not limited to: Review of construction documents on 9/9/2024 at 9:00 am revealed that air supplied to the patient rooms and corridor of the patient area was not being returned to a mechanical unit. Exhaust fans were shown in patient bathrooms. Observations on 9/10/2024 at 10:55 am revealed that air was circulating from patient rooms into the patient corridor. Smoke from a lighted incense stick could be observed flowing from the direction of the patient room to the corridor when held at the bottom of the patient room doors when closed. When the exhaust fans within the patient room bathrooms were turned on, the direction of the smoke became vertical, indicating a neutral pressure. The exhaust fans were switched to come on with the patient bathroom lights. No other exhaust or return air was provided to the patient rooms, except in the airborne isolation rooms that had continuously running exhaust fans. In an interview with the Mechanical Engineer at approximately 11:15 a.m. on 9/10/2024, they stated that no return or exhaust air was accounted for in the mechanical design of the system. They stated that balancing of supply air was to be accomplished by building leakage. In an interview with the GC at approximately 11:30 a.m. on 9/10/2024, they stated that they did not have a test and balance report available to demonstrate the required pressure relationships and air changes per hour. In a record review on 9/19/2024, of a Test and Balance report dated 9/19/2024 provided by the G.C. on 9/19/2024, the measured cubic feet per minute (CFM) of airflow for each space was provided, however, room volumes were not provided. Information regarding required air changes per hour (ACH) could not be determined from the provided information. Additionally, exhaust Fan-19 was reported as having a design airflow of 100 CFM and a final airflow of 80-82 CFM, a deviation of approximately 19%. Standard deviations are 7 to 10%, per the report. Observations on 9/12/2024 at 1:20 p.m. revealed that the medical vacuum exhaust discharge was located 11 feet from the outside air intake of the HVAC unit on the flat roof area of the facility. The exhaust for the two dryers serving the facility was 15 feet from the outside air intake. A plumbing vent discharge was located 20 feet from the outside air intake of the unit. Refer to ASHRAE 170 section 6.3.3.1. References: 42 CFR 418.110 Standard: Building Safety. Except as otherwise provided in this section, the hospice must meet the applicable provisions and must proceed in accordance with the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12–2, TIA 12–3, TIA 12–4, TIA 12–5 and TIA 12–6). NFPA 99, 2012 Edition9.3 General.9.3.1 Heating, Cooling, Ventilating, and Process Systems.9.3.1.1 Heating, cooling, ventilating, and process systems serving spaces or providing health care functions covered by this code or listed within ASHRAE 170, Ventilation of Health Care Facilities, shall be provided in accordance with ASHRAE 170. ASHRAE/ASHE 170-2008 Ventilation of Health Care Facilities6.3 Outdoor Air Intakes and Exhaust Discharges 6.3.1 Outdoor Air Intakes. 6.3.1.1 General Outdoor air intakes for airhandling units shall be located a minimum of 25 ft (8 m) from cooling towers and all exhaust and vent discharges. Outdoor air intakes shall be located such that the bottom of the air intake is at least six ft (2 m) above grade. Intakes on top of buildings shall be located a minimum of three ft (1 m) above roof level. New facilities with moderate-to-high risk of natural or man-made extraordinary incidents shall locate air intakes away from public access. All intakes shall be designed to prevent the entrainment of wind-driven rain, shall contain features for draining away precipitation and shall be equipped with a birdscreen of mesh no smaller than 0.5 in. (13 mm). 6.7 Air Distribution Systems 6.7.1 General. Maintain the pressure relationships required in Table 7-1 in all modes of HVAC system operation, except as noted in the table. Spaces listed in Table 7-1 that have required pressure relationships shall be served by fully ducted return systems or fully ducted exhaust systems. The following additional surgery and critical care patient care areas that do not require a pressure relationship to adjacent areas shall also be served by fully ducted return or exhaust systems: 1) recovery rooms, 2) critical and intensive care areas, 3) intermediate care areas, and 4) wound intensive care units (burn units). In inpatient facilities, patient care areas shall utilize ducted systems for return and exhaust air. Where space pressure relationships are required, the air-distribution system design shall maintain them, taking into account recommended maximum filter loading, heating-season lowered airflow operation, and cooling-season higher airflow operation. Airstream surfaces of the air-distribution system downstream of Filter Bank No. 2, shall comply with Section 5.5 of ANSI/ASHRAE Standard 62.1-2007. The air-distribution system shall be provided with access doors, panels, or other means to allow convenient access for inspection and cleaning. (For further information, see ANSI/ASHRAE Standard 62.1.) 2008 NFPA 170 Ventilation for Healthcare Facilities References:Table 7-1 (excerpt) Room / Pressure Relationship / Outdoor ACH /Total ACHResident Room / NR / 2 / 2Resident gathering/activity/dining / NR / 4 / 4Soiled workroom or soiled holding room / Negative / 2 / 10 Clean work room or clean holding (utility) Positive / 2 / 4Food Preparation Center / NR / 2 / 10Bathroom / Negative / NR / 10Janitor closet / Negative / NR / 10Soiled or decontamination room / Negative / 2 / 6Clean workroom / Positive / 2 / 4Ware washing / Negative / NR / 10Dietary Storage / NR / 2 / NRClean Linen / Positive / NR / 2 NR = No requirement”

“Based on observation, interview and record review, the essential electric system alarm annunciator failed to meet the requirements of NFPA 110, 2010 Edition 6.4.1.1.16.2, as referenced by 42 CFR 418.110 (e). The facility failed to provide an indication for remote emergency stop of the generator. Observations on 9/11/2024 starting at 1:00 p.m. revealed that the indicator light on the generator annunciator did not indicate when a remote stop of the generator was initiated. In an interview with the GC on 9/11/2024, he agreed that the indicator light for the generator did not illuminate when a test of the remote stop was performed. In a record review on 9/10/2024, the facilities NFPA 99 risk assessment noted a category 1 electrical system was required for hospice resident rooms and nursing station, and for the generator/electrical assessment in the maintenance category. A risk category of 1 was assigned to electrical equipment of Bipap/Cpap machines, defirillator, oxygen concentrator and regulator, tube feed pumps, oxygen storage tanks. 42 CFR 418.110(e) Standard: Building Safety. Except as otherwise provided in this section, the hospice must meet the applicable provisions and must proceed in accordance with the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12–2, TIA 12–3, TIA 12–4, TIA 12–5 and TIA 12–6). NFPA 110, 2010 Edition6.4.1.1.16 Requirements for Safety Devices.6.4.1.1.16.2 Safety indications and shutdowns shall be in accordance with Table 6.4.1.1.16.2. Table 6.4.1.1.16.2 Safety Indications and ShutdownsLevel 1Indicator Function (at Battery Voltage) CV S RA(a) Overcrank X X X(b) Low water temperature X — X(c) High engine temperature pre-alarm X — X(d) High engine temperature X X X(e) Low lube oil pressure pre-alarm X — X(f) Low lube oil pressure X X X(g) Overspeed X X X(h) Low fuel main tank X — X(i) Low coolant level X O X(j) EPS supplying load X— —(k) Control switch not in automaticposition X — X(l) High battery voltage X — —(m) Low cranking voltage X — X(n) Low voltage in battery X — —(o) Battery charger ac failure X — —(p) Lamp test X — —(q) Contacts for local and remotecommon alarm X — X(r) Audible alarm-silencing switch — — X(s) Low starting air pressure X — —(t) Low starting hydraulic pressure X — —(u) Air shutdown damper when used X X X(v) Remote emergency stop — X —CV: Control panel–mounted visual. S: Shutdown of EPS indication.RA: Remote audible. X: Required. O: Optional”

“Based on observation, record review, and interview, the facility failed to install and test the essential electrical system in accordance with NFPA 99, NFPA 110 and NFPA 70 as referenced by 42 CFR 418.110(e). Findings include, but are not limited to: A) Generator 1. The facility failed to protect the emergency generator from vehicular traffic in accordance with section 110.26(E)(2) of NFPA 70, as referenced by 42 CFR 418.110 (e), NFPA 99 section 15.5.1.3, and section 5.6.9 of NFPA 110. Observations on 9/11/2024 at 9:00 a.m. revealed that the emergency generator was located outside directly adjacent to the fire lane that is also used for ambulance drop-off and service vehicle traffic. The generator was not protected by an enclosure or bollards to prevent a vehicle from striking the generator. 2. The facility failed to provide initial acceptance testing and documentation in accordance with NFPA 110 section 7.13, as referenced by 42 CFR 418.110 (e) and NFPA 99 section 15.5.1.3. The facility conducted a 2-hour load test of the EPSS, but did not initiate a 2-hour full load test following a 5-minute cooldown as required by NFPA 110 section 7.13.4.2, 7.13.4.3, and 17.4.3.1 .The facility failed to supply manuals for major components of the EPSS (generator and transfer switches) in accordance with NFPA 110 section 8.2. Record review on 9/11/2024 at 1:00 pm revealed that the installation load bank test for the generator was conducted for a period of 2 hours, starting with a load of 25% of the nameplate for 30 minutes, 50% for 30 minutes, 75% for 30 minutes, and 100% for 30 minutes. No additional load tests were performed. Copies of the generator manual and transfer switch, a certified analysis, a letter of compliance, and manufacturers certification were not included in the facilitys documentation. This load bank test does not meet the requirements for a new generator installation. An interview with the GC 9/11/2024 at 1:00 pm revealed that no additional load testing was performed on the generator, and no additional documentation regarding installation acceptance was provided. Copies of the generator manual and transfer switch, a certified analysis, a letter of compliance, and manufacturers certification were not provided by the generator installer. 3. The facility failed to provide transfer of power to alternate power within 10 seconds as required by NFPA 110 section 4.4.4 and NFPA section 6.4.1.1.6.1. Observations on 9/12/2024 at approximately 2:00 pm revealed that the time to transfer from normal power to alternate power during a test of the generator was 12.5 seconds. In an interview with the GC on 9/12/2024 at approximately 2:00 pm, the GC agreed that the transfer to alternate power during a test of the generator exceeded 10 seconds. References: 42 CFR 418.110 (e) Standard: Building Safety. Except as otherwise provided in this section, the hospice must meet the applicable provisions and must proceed in accordance with the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12–2, TIA 12–3, TIA 12–4, TIA 12–5 and TIA 12–6). NFPA 99, 2012 EditionChapter 6 Electrical Systems6.4 Essential Electrical System Requirements – Type 6.4.1.1.6.1 Type 1 and Type 2 essential electrical system power sources shall be classified as Type 10, Class X, Level 1 generator. Chapter 15 Features of Fire protection15.5.1.3 Emergency Generators and Standby Power Systems.Emergency generators and standby power systems, where required for compliance with this code, shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 2010 EditionChapter 4 Classification of Emergency4.4.4 Level 1 and Level 2 systems shall ensure that all loads served by the EPSS are supplied with alternate power that meets all the following criteria: (1) Of a quality within the operating limits of the load(2) For a duration specified for the class as defined in Table 4.1(a)(3) Within the time specified for the type as defined in Table 4.1(b) Table 4.1(b) Types of EPSSs Designation Power Restoration Type U: Basically uninterruptible (UPS systems) Type 10: 10 secType 60: 60 secType 120: 120 secType M: Manual stationary or nonautomatic —no time limit Chapter 5 Emergency Power Supply (EPS): Energy Sources, Converters, and Accessories 5.2 Energy Converters – General5.2.1.2 The capability of the energy converter, with its controls and accessories, to survive without damage from common and abnormal disturbances in actual load circuits shall be demonstrable by tests on separate prototype models, or by acceptable tests on the system components as performed by the component suppliers, or by tests performed in the listing process for the assembly. 5.6 Rotating Equipmen5.6.9 Generators, Exciters, and Voltage Regulators. Generators shall comply with Article 445 of NFPA 70, National Electrical Code, and with the requirements of 5.6.9.1 through 5.6.9.95.6.10.2 A certification shall be supplied with the unit that verifies the torsional vibration compatibility of the rotating element of the prime mover and generator for the intended use of the energy converter5.6.10.5 The energy converter supplier shall stipulate compliance and performance with this standard for the entire unit when installed. 7.13 Installation Acceptance7.13.1 Upon completion of the installation of the EPSS, the EPS shall be tested to ensure conformity to the requirements of the standard with respect to both power output and function7.13.2 An on-site acceptance test shall be conducted as a final approval test for all EPSSs.7.13.2.1 For new Level 1 installations, the EPSS shall not be considered as meeting this standard until the acceptance tests have been conducted and test requirements met.7.13.2.2 The test shall be conducted after completion of the installation with all EPSS accessory and support equipment in place and operating. 7.13.4.1 The on-site installation acceptance test shall be conducted in accordance with 7.13.4.1.1 through 7.13.4.1.3.7.13.4.1.1 In a new and unoccupied building or facility, with the prime mover in a cold start condition and the emergency load at operating level, a normal power failure shall be initiated by opening all switches or circuit breakers supplying the normal power to the building or facility.7.13.4.1.2 In an existing occupied building or facility, with the prime mover in a cold start condition and the emergency load at operating level, a normal power failure shall be simulated by operating at least one transfer switch test function or initiated by opening all switches or breakers supplying normal power to all ATSs that are part of the EPSS being commissioned by this initial acceptance test. 7.13.4.1.3 The tests conducted in accordance with 7.13.4.1.1 and 7.13.4.1.2 shall be performed in accordance with (1) through (12). (1) When the EPSS consists of paralleled EPSs, the quantity of EPSs intended to be operated simultaneously shall be tested simultaneously with building load for the test period identified in 7.13.4.1.3(10). Subsection 7.13.4.1.3(1) was revised by a tentative interim amendment (TIA). See page 1. (2) The test load shall be all loads that are served by the EPSS. There is no minimum loading requirement for this portion of the test.(3) The time delay on start shall be observed and recorded.(4) The cranking time until the prime mover starts and runs shall be observed and recorded.(5) The time taken to reach operating speed shall be observed and recorded.(6)*The engine start function shall be confirmed by verifying operation of the initiating circuit of all transfer switches supplying EPSS loads.(7) The time taken to achieve a steady-state condition with all switches transferred to the emergency position shall be observed and recorded.(8) The voltage, frequency, and amperes shall be recorded.(9) Where applicable, the prime mover oil pressure and water temperature shall be recorded.(10) The load test with building load, or other loads that simulate the intended load as specified in Section 5.4, shall be continued for not less than 1.5 hours, and the run time shall be recorded.(11) When normal power is restored to the building or facility, the time delay on retransfer to normal power for each switch with a minimum setting of 5 minutes shall be recorded.(12) The time delay on the prime mover cooldown period and shutdown shall be recorded. 7.13.4.2 After completion of the test performed in 7.13.4.1, the prime mover shall be allowed to cool for not less than 5 minutes.7.13.4.3 A load shall be applied for a 2-hour, full-load test. The building load shall be permitted to serve as part or all of the load, supplemented by a load bank of sufficient size to provide a load equal to 100 percent of the nameplate kW rating of the EPS, less applicable derating factors for site conditions.7.13.4.3.1 This full-load test shall be initiated after the test specified in 7.13.4.1.3 by any method that starts the prime mover and, upon reaching rated rpm, picks up not less than 30 percent of the nameplate kW rating for the first 30 minutes, not less than 50 percent of the nameplate kW rating for the next 30 minutes, and 100 percent of the nameplate kW rating for the next 60 minutes, less applicable derating factors for site conditions. 7.13.4.6 Items (1) through (4) shall be made available to the authority having jurisdiction at the time of the acceptance test: (1) Evidence of the prototype test as specified in 5.2.1.2 (for Level 1 systems)(2) A certified analysis as specified in 5.6.10.2(3) A letter of compliance as specified in 5.6.10.5(4) A manufacturers certification of a rated load test at rated power factor with the ambient temperature, altitude, and fuel grade recorded Chapter 8 Routine Maintenance and Operational Testing 8.2 Manuals, Special Tools, and Spare Parts.8.2.1 At least two sets of instruction manuals for all major components of the EPSS shall be supplied by the manufacturer(s) of the EPSS and shall contain the following: (1) A detailed explanation of the operation of the system(2) Instructions for routine maintenance(3) Detailed instructions for repair of the EPS and other major components of the EPSS(4) An illustrated parts list and part numbers(5) Illustrated and schematic drawings of electrical wiring systems, including operating and safety devices, control panels, instrumentation, and annunciators 8.2.2 For Level 1 systems, instruction manuals shall be kept in a secure, convenient location, one set near the equipment, and the other set in a separate location. NFPA 70, 2011 Edition II. 600 Volts, Nominal, or Less110.26 Spaces About Electrical Equipment. (E) Dedicated Equipment Space.(2) Outdoor. Outdoor electrical equipment shall be installed in suitable enclosures and shall be protected from accidental contact by unauthorized personnel, or by vehicular traffic, or by accidental spillage or leakage from piping systems. The working clearance space shall include the zone described in 110.26(A). No architectural appurtenanceor other equipment shall be located in this zone.”

“Observed in Data Session. During survey activities it was noted that organization leaders did not ensure review, approval, management, and implementation of policies and procedures that guide, and support Volunteer Services was completed. For example, all requirements related to the Condition of Participation 418.78 – Volunteer Services - were not met as evidenced by: 1) Effective recruitment of volunteers was not completed, 2) The dollar costs savings achieved through the use of volunteers was not documented, and 3) Volunteer staff did not provide volunteer services in an amount that equals 5% of the total patient care hours of all paid hospice employees and contract staff. This observation was reviewed with agency leadership.”

“Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that the organization did not ensure the plan of care goals included outcome measures for specific care activities. For example, a review of the medical record for RRHV#1, revealed that the patient’s terminal illness diagnosis was Malignant Neoplasm of Prostate. The plan of care did not include a goal statement to evaluate the response to care, treatment, and services related to Malignant Neoplasm of Prostate interventions. In addition, an updated nursing assessment completed on day 2 of services documented a pain score of (7) - coded as severe on the organization’s pain scale tool. A review of the History and Physical revealed that the patient had a history of experiencing severe pain. The plan of care did not include a goal statement to evaluate the response to care, treatment, and services related to pain management. This observation was reviewed with agency leadership.”

“Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that the organization did not ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. For example, a review of the medical record for RRHV#1, revealed that the patient’s terminal illness diagnosis was Malignant Neoplasm of Prostate. The plan of care did not include interventions to manage care, treatment, and services related to Malignant Neoplasm of Prostate. In addition, an updated nursing assessment completed on day 2 of services documented a pain score of (7) - coded as severe on the organization’s pain scale tool. A review of the History and Physical revealed that the patient had a history of experiencing severe pain. The plan of care did not include interventions to manage pain symptoms. This observation was reviewed with agency leadership.”

“Observed in Record Review. In 2 of 10 patient records reviewed, it was noted that the organization did not ensure the plan of care was revised when the patient’s condition changed. For example, a review of the medical record for RRNHV#2, revealed that the comprehensive assessment update completed during benefit period #6, documented that the patient had experienced 4 falls. The plan of care was not updated with interventions to maintain safety and strategies to prevent injury. 

Example #2: A review of the medical record for RRNHV#7, revealed that the comprehensive assessment update completed during benefit period #5, documented that the patient had experienced 2 falls. The plan of care was not updated with interventions to maintain safety and strategies to prevent injury. This observation was reviewed with agency leadership.”

“Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that the organization did not ensure all requirements related to a comprehensive assessment being completed within 5 days of the start of care were implemented. For example, during a review of the medical record for RRHV#1, it was noted that the Spiritual Counselor did not complete an initial spiritual assessment. A continued review of the medical record revealed that no other discipline completed a spiritual assessment that met the agency policy for assessment of spiritual needs. In addition, the patient’s terminal illness diagnosis was Malignant Neoplasm of Prostate. The initial comprehensive nursing assessment did not include an assessment of the patient’s genitourinary or reproductive systems. This observation was reviewed with agency leadership. 
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“Observed in Data Session. Since volunteer recruitment and retention initiatives were ineffective the organization was not able to document how the use of volunteer services helped the organization demonstrate cost savings. For example, a review of volunteer work time revealed that volunteer staff did not provide volunteer services in an amount that equals 5% of the total patient care hours of all paid hospice employees and contract staff for the year(s) 2023 and 2024. In addition, the organization did not document the cost savings dollar amount achieved through the use of volunteers for 2023 and 2024. This observation was reviewed with agency leadership.”

“Observed in Data Session. The organization was not able to demonstrate that volunteer staff provided day-to-day administrative or direct patient care in an amount that achieved cost savings. For example, a review of volunteer work time revealed that volunteer staff did not provide volunteer services in an amount that equals 5% of the total patient care hours of all paid hospice employees and contract staff for the year(s) 2023 and 2024. The actual cost savings for 2023 was 2%. The actual cost savings to date for 2024 was 2%. This observation was reviewed with agency leadership.”