Massac Memorial Hospital

“On November 25, 2024, the Life Safety Code portion of a Re-Certification Survey was conducted. The surveyor was accompanied during the survey walk-through by the following provider representatives: Staff and Vendor Information: E-1 Maintenance Manager E-2 Chief Facilities Officer V-1 Sprinkler Inspection Company The building, constructed in 1956 with additions constructed in 1994 and 2008, was observed to include 1 building story plus a basement and a mechanical penthouse, to be of Type II(000) construction, and to be fully covered by an automatic sprinkler system. The facility was surveyed as an existing health care occupancy under the 2012 Edition of the NFPA 101 Life Safety Code, including Chapter 19. Unless otherwise noted, those code sections listed herein that do not include a reference to a specific NFPA code and year of issue (such as NFPA 99 2012) are taken from the 2012 Edition of the NFPA 101 Life Safety Code. Unless otherwise noted, all deficiencies cited herein were found through observation during the survey walk-through, staff interview, or document review. The requirements of 42 CFR Subpart 485.623 Physical Plant and Environment are NOT MET as evidenced by the deficiencies cited under the following K-Tags.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 45539 Based on document review and interview, the facility failed to provide a complete fire alarm system with coverage throughout the entire facility. This deficient practice could affect all patients, in all Smoke Zones, as well as an indeterminable number of staff and visitors if the fire-alarm system failed to notify occupants and the fire department in a fire emergency. Findings include: A. On 11/25/24at 1:45 PM, during review of the Fire Alarm System Inspection and Testing Report and by interview with E-1 and E-2, it was revealed that the facility failed to have all the devices, attached to the fire alarm system, tested to determine if they are fully functional in the past 12 months. This did not meet the requirements of NFPA 72, 2010 Edition, Section 14.4 and Table 14.3.1(9) and LSC; Section 9.6.1.4. B. On 11/25/24at 1:45 PM, during review of the Fire Alarm System Inspection and Testing Report and per interview with E-1 and E-2, the facility failed to provide current records for the required Semi-Annual Visual Fire Alarm System Inspection with an itemized list and a physical address for each Fire Alarm Device and Fire Alarm Panels in accordance with NFPA 72, 2010 Edition, Section 14.4.5 and Table 14.4.5.”

“Fire Alarm System - Out of Service CFR(s): NFPA 101 Fire Alarm - Out of Service Where required fire alarm system is out of services for more than 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 This Standard is not met as evidenced by: 45539 Based on document review, the facility failed to establish a proper Fire Watch Policy and Fire Watch Training of staff for procedures that must conducted when the Fire Alarm System is out of service for more than 4 hours in a 24-hour period. This deficient practice could affect all patients in all Smoke Zones, as well as an indeterminable number of staff and visitors, if staff did not conduct the proper procedures when the fire alarm system was inoperable. Findings include: A. On 11/25/24 at 2:25 PM, accompanied by E1 and E2 Document Review and staff interview, revealed that the facility did not provide complete training records of staff conducting the fire watch for notification procedures, extinguishment training and fire prevention and is not in accordance with the requirements of NFPA 101, 2012 Edition, Section 9.6.1.6. B. On 11/25/24 at 2:25 PM, accompanied by E1 and E2 Document Review and staff interview, revealed the facility failed to establish a proper written policy indicating the procedures the facility must initiate when a required fire alarm system is out of service for more than 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 the parties left unprotected by the shutdown until the fire alarm system has been returned to service in accordance with NFPA 101, 2012 Edition, Section 9.6.1.8. Examples of missing Key Directives: 1. Facility shall provide policy and procedures when the fire alarm system is out of service for more than 4 hours in a 24-hour time frame the facility shall evacuate effected portions of the building or provide an approved Fire Watch. NFPA 101, 2012 Edition Section 9.6.1.6. 2. IDPH Regional Office (AHJ) shall be notified. 3. Fire Watch policy and procedures include the following as interpreted by the AHJ and NFPA 101, 2012 Edition Section 3.3.104, Which Reads: “The assignment of a person or persons to an area for the express purpose of notifying the fire department, the building occupants, or both of an emergency; preventing a fire from occurring; extinguishing small fires; or protecting the public from fire or life safety dangers. NFPA 101, 2012 Edition Section 3.3.104 (1) Training records of staff conducting the fire watch for notification procedures, extinguishment training and fire prevention. (2) The fire watch is continuous (3) The personnel conducting the fire watch shall have no other duties. (4) A method of recording and documenting the fire watch (5) Identification of Staff performing the Fire Watch (6) Access to all spaces provided to Fire Watch Staff (keys, codes or badges)”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 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 This Standard is not met as evidenced by: 45539 Based on document review the facility failed to maintain the sprinkler system. This deficient practice could affect all patients in all Smoke Zones, as well as an indeterminable number of staff and visitors, if the sprinkler system failed to operate during a fire emergency due to a lack of required maintenance. Findings include: A. On 11/25/24 at 1:52 PM, accompanied by E1 and E2 during review of the Sprinkler System Inspection Reports it was revealed that the facility failed to provide three (3) of the four (4) required quarterly sprinkler inspections within the past twelve (12) months in accordance with NFPA 25; 2011 Edition, Section 5.1.1.2 and Table 5.1.1.2. Example of missing inspections include: 1. 1st Quarter 2024 2. 2nd Quarter 2024 3. 3rd Quarter 2024 B. On 11/25/24 at 1:52 PM, accompanied by E1 and E2 during review of the Sprinkler System Inspection Reports it was revealed that the facility had no documents indicating that the sprinkler system’s piping has received internal inspection in the past 5-years. This did not meet the requirements of NFPA 25; 2011 Edition, Section 14.2.1. An inspection of piping and branch line conditions shall be conducted every 5 years. C. On 12/07/10 at 12:50 PM, during document review and by interview with E-1 and E-2, it was revealed that the facility failed to have necessary repairs made to the Sprinkler System. Per the Annual Sprinkler System Inspection by V-1, three (3) items were noted as having “FAILED.” Per an interview with E-1 and E-2, it was noted that none of these items have been corrected and are still deficient. The facility had no documentation of repairs. The following three items were noted as “Non approved antifreeze solution in system per NFPA 24”: 1. Wet Pipe, ER awning antifreeze 2. Wet Pipe, front awning antifreeze 3. Wet Pipe, old ambulance Dock (antifreeze) D. On 11/25/24 at 3:01 PM, while accompanied by E-1 and E-2, an observation revealed that the Food Service Smoke Zone - walk-in refrigerator had one (1) dirty sprinkler head. This sprinkler head was loaded with corrosion and must be replaced in accordance with NFPA 25; 2011 Edition, Section 5-2.1.1.2 and NFPA 101; 2012 Edition, Section 9.7. E. On 11/25/24 at 3:05 PM, while accompanied by E-1 and E-2, an observation revealed that the Food Service Smoke Zone - Kitchen had six (6) dirty sprinkler heads. These sprinkler heads were loaded with corrosion and must be replaced in accordance with NFPA 25; 2011 Edition, Section 5-2.1.1.2 and NFPA 101; 2012 Edition, Section 9.7.”

“Sprinkler System - Out of Service CFR(s): NFPA 101 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. 18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25) This Standard is not met as evidenced by: 45539 Based on document review, the facility failed to establish a proper Fire Watch Policy and Fire Watch Training of staff for procedures that must conducted when the Sprinkler System is out of service for more than 10 hours in a 24-hour period. This deficient practice could affect all patients in all Smoke Zones, as well as an indeterminable number of staff and visitors, if staff did not conduct the proper procedures when the sprinkler system was inoperable. Findings include: A. On 1/25/24 at 1:52 PM, accompanied by E1 and E2 Document Review and staff interview, revealed that the facility did not provide complete training records of staff conducting the fire watch for notification procedures, extinguishment training and fire prevention and is not in accordance with the requirements of NFPA 101, 2012 Edition, Section 9.6.1.6. B. On 1/25/24 at 1:52 PM, accompanied by E1 and E2 Document Review and staff interview, revealed the facility failed to establish a proper written policy indicating the procedures the facility must initiate when a required sprinkler system is out of service for more than 10 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 the parties left unprotected by the shutdown until the sprinkler system has been returned to service in accordance with NFPA 25; Section, 2011 Edition Section 15.5.2(6). Examples of missing Key Directives: 1. Impairment Coordinator is established in accordance with NFPA 25, 2011 Edition Section 15.2.1 2. Impairment tags are posted at each fire department connection and control valves in accordance with NFPA 25, 2011 Edition Section 15.3.2 3. Where a required automatic sprinkler system is out of service for more than 10 hours in a 24-hour period the impairment coordinator shall arrange for one of the following in accordance with NFPA 25, 2011 Edition Section 15.5.2(4): (1) Evacuation of the building or portion of the building affected by the service outage (2) An approved Fire Watch 4. Fire Watch policy and procedures shall include the following as interpreted by the AHJ and NFPA 101, 2012 Edition Section 3.3.104, Which Reads: “The assignment of a person or persons to an area for the express purpose of notifying the fire department, the building occupants, or both of an emergency; preventing a fire from occurring; extinguishing small fires; or protecting the public from fire or life safety dangers in accordance with NFPA 101, 2012 Edition Section 3.3.104: (1) Training records of staff conducting the fire watch for notification procedures, extinguishment training and fire prevention. (2) The fire watch is continuous (3) The personnel conducting the fire watch have no other duties (4) A method of recording and documenting the fire watch (5) Identification of Staff performing the Fire Watch (6) Access to all spaces provided to Fire Watch Staff (keys, codes or badges) 5. When the sprinkler is out of service the facility shall notify the following in accordance with NFPA 25, 2011 Edition Section 15.5.2(6): (1) The insurance carrier (2) The alarm company (3) IDPH Regional Office (4) All other authorities having jurisdiction 6. Restoring System to Service the following are provided: (1) Necessary inspections and tests have been conducted to verify that the effected systems are operational (2) Supervisors are notified (3) Fire Department is notified (4) Property Owner or designated representative, Insurance Carrier, Alarm Company, IDPH and other AHJs are notified (5) Impairment tags are removed”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 45539 Based on document review the facility failed to maintain fire rated building separation doors. This deficient practice could affect all patients in all Smoke Zones, as well as an indeterminable number of staff and visitors, if the fire rated doors failed to function and keep the integrity of the rated opening during a fire. Findings include: On 11/25/24 at 3:30 PM accompanied by E1 and E2 document review revealed to facility failed to provide records for the annual testing and inspection of the required fire rated doors of the facility, in accordance with NFPA 80, 2010 Edition, Section 5.2.4, NFPA 101; 2012 Edition, Section 7.2.1.15. The Fire Door Inspection report provided was dated 05/09/23.”

“LIFE SAFETY FROM FIRE CFR(s): §485.623(c) Standard: Life Safety From Fire (1) Except as otherwise provided in this section: (i) The CAH must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. This Standard is not met as evidenced by: 45539 Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Recertification Survey conducted on November 25, 2024, the surveyor finds that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code. See the Life Safety Code deficiencies identified with K-Tags.”