Northern Cochise Community Hospital, Inc.

“Multiple Occupancies CFR(s): NFPA 101 Multiple Occupancies - Sections of Health Care Facilities Sections of health care facilities classified as other occupancies meet all of the following: o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access. o They are separated from areas of health care occupancies by construction having a minimum two hour fire resistance rating in accordance with Chapter 8. o The entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served. 19.1.3.3, 42 CFR 482.41, 42 CFR 485.623 This Standard is not met as evidenced by: 43814 Based on the requirement to minimum NFPA 101-chapter 19 fire protection features such as 2-hour separation, sprinkler, and alarm function for the hospital. The facility failed to meet this requirement for the Physical therapy area. Failure to provide the minimum fire protection features could cause serious injury or death in the event of a fire NFPA 101: Life Safety Code, 2012 Edition - Chapter 19 Existing Health Care Occupancies 19.1.2 Classification of Occupancy. 6.1.5.1 * Definition - Health Care Occupancy. An occupancy used to provide medical or other treatment or care simultaneously to four or more patients on an inpatient basis, where such patients are mostly incapable of self-preservation due to age, physical or mental disability, or because of security measures not under the occupants’ control. 19.1.3.4 Contiguous Non-Health Care Occupancies. 19.1.3.4.1 * Ambulatory care facilities, medical clinics, and similar facilities that are contiguous to health care occupancies, but are primarily intended to provide outpatient services, shall be permitted to be classified as business occupancies or ambulatory health care facilities, provided that the facilities are separated from the health care occupancy by not less than 2-hour fire resistance-rated construction, and the facility is not intended to provide services simultaneously for four or more in patients who are litter borne. 19.1.3 Multiple Occupancies. 19.1.3.3 * Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions: 1. They are not intended to provide services simultaneously for four or more inpatients for purposes of housing, treatment, or customary access by inpatients incapable of self-preservation. 2. They are separated from areas of health care occupancies by construction having a minimum 2-hour fire resistance rating in accordance with Chapter 8. 3. For other than previously approved occupancy separation arrangements, the entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. NFPA 101 2012 Edition, Section 8.2 Construction and Compartmentation. 8.2.1.1 Buildings or structures occupied or used in accordance with the individual occupancy chapters, Chapters 11 through 43, shall meet the minimum construction requirements of those chapters. 8.2.1.2 * NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification. 8.2.1.3 Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on one of the following: (1) Separate buildings, if a 2-hour or greater vertically aligned fire barrier wall in accordance with NFPA 221, Standard for High Challenge Fire Walls, Fire Walls, and Fire Barrier Walls, exists between the portions of the building. (2) Separate buildings, if provided with previously approved separations. (3) Least fire-resistive construction type of the connected portions, if separation as specified in 8.2.1.3(1) or (2) is not provided. Findings: Observations made while on tour on July 15-16, 2024 revealed the facility’s physical therapy outpatient treatment center is not separated from the hospital by a 2-hour firewall and is missing a fire-rated door. Employee #1 confirmed during the exit conference on July 16 that the facility’s physical therapy outpatient treatment center is not separated from the hospital by a 2-hour firewall and is missing a fire-rated door does meet the requirements of NFPA 101 Chapter 19 Existing Health Care Occupancies.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 43814 Based on observation, the facility failed to prevent correctly typed fire extinguishers from the stored class B fuel used for the generators. Failing to have clear access to a fire extinguisher during an emergency could result in harm to the patients and/or staff. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.12 “Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1” Section 9.7.4.1 “Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for portable Fire Extinguishers.” NFPA 10, Chapter 7, Section 7.2.2 Periodic inspections or electronic monitoring of fire extinguishers shall include a check of at least the following items: No obstruction to access or visibility. NFPA 30: Flammable and Combustible Liquids Code, 2012 Edition - Chapter 4 Definition and Classification of Liquids 4.2.2 Combustible Liquid. Any liquid that has a closed-cup flash point at or above 100°F (37.8°C), as determined by the test procedures and apparatus set forth in Section 4.4. Combustible liquids are classified according to Section 4.3. NFPA 10: Standard for Portable Fire Extinguishers, 2010 Edition - Chapter 5 Selection of Portable Fire Extinguishers 5.2.2 Class B Fires. Class B fires are fires in flammable liquids, combustible liquids, petroleum greases, tars, oils, oil-based paints, solvents, lacquers, alcohols, and flammable gases. 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. Table 6.3.1.1 Fire Extinguisher Size and Placement for Class B Hazards Type of Hazard Basic Minimum Extinguisher Rating Maximum Travel Distance to Extinguishers ft m (moderate) 20-B 50 Notes: (1) The specified ratings do not imply that fires of the magnitudes indicated by these ratings will occur, but rather they are provided to give the operators more time and agent to handle difficult spill fires that have the potential to occur. (2) For fires involving water-soluble flammable liquids, see 5.5.3. (3) For specific hazard applications, see Section 5.5. 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.) Findings include: During a facility tour conducted on July 15, 2024, revealed that the two facility generators did not have a 20 lb B rated extinguisher within 50 of thea class B diesel fuel. Employee #1 confirmed during the exit conference on July 16, 2024, that the two generators did not have rated extinguishers within 50 feet of the fuel storage.”