Hamilton Memorial Hospital

“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: 42887 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 July 15, 2025, 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.”

“On July 15, 2025, the Life Safety Code portion of the Recertification survey was conducted. The surveyor was accompanied during all or part of the survey walk-through by one or all of the following provider representatives: The Safety Officer (SO). Chief Nursing Officer (CNO) Quality & Risk Management Director (QRMD) The one story building, constructed in 1958 (with additions in 1960, 1970, and 2008), was observed 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 70-2011) 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.”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 42887 Based on observation, the facility failed to install and maintain emergency illumination components as required. This deficient practice could affect patients, visitors, and staff because failure of emergency lighting would render occupants unable to navigate and emergency event. The findings are: A. On July 15, 2025 at 3:30pm, while in the company of CNO and QRMD evidence of monthly functional testing for a minimum of 30-seconds for the emergency battery-operated lights was unavilable for review. This does not comply with 7.9.3.1.1.(1). B. On July 15, 2025 at 3:30pm, while in the company of CNO and QRMD evidence of annual 90-minute functional test of for the battery-operated emergency lights was unavilable for review. This does not comply with 7.9.3.1.1.(3).”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 42887 Based on observation, the facility failed to install and maintain exit signage components as required. This deficient practice could affect patients, visitors, and staff because failure of exit signage would render occupants unable to navigate to an exit during an emergency event. The findings is: On July 15, 2025 at 3:30pm, while in the company of CNO and QRMD evidence of monthly visual inspection for battery-operated Exit Signs was unavilable for review. This does not comply with 7.10.9.1”

“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: 42887 Based upon documentation, fire alarm system components are not maintained in accordance with Code requirements. Failure to install components in accordance with requirements can result in failure of the system to operate as intended and delay proper repairs when necessary. Findings include: A. On July 15, 2025 at 3:30pm, while in the company of CNO and QRMD evidence of two visual inspections of all the devices of the fire alarm system within the last 12 months in accordance with NFPA 72-2010 Edition, 14.3.1. and Table 14.3.2. was unavailable for review. B. On July 15, 2025 at 3:30pm, while in the company of CNO and QRMD evidenceof the annual functional testing of alarm initiating and notifying fire alarm devices within the last 12 months in accordance with NFPA 72-2010, 7.3.1. and Table 7.3.2.”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 42887 Based on observation the facility lacks complete sprinkler protection. Failure to install and maintain this installation could result in delayed response and fire suppression. This deficient practice could affect patients, staff and visitors during a fire event. Findings include: On July 15, 2025 at 2:30pm while in the company of the QRMD and SO, it was observed in the storage room off the purchasing hallway that the room is not provided with fire sprinkler protection. This is not in compliance with NFPA 13-2010, 8.1.”

“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: 42887 Based upon documentation, fire supression system components are not maintained in accordance with Code requirements. Failure to install components in accordance with requirements can result in failure of the system to operate as intended and delay proper repairs when necessary. Findings include: A. On July 15, 2025 at 1:30pm, while in the company of CNO and QRMD it was observed that a sprinkler head over the Emergency Department entrance was missing an escutcheon ring. This does not comply with NFPA 13-2010, 6.2.7.1. B. On July 15, 2025 at 2:30pm, while in the company of CNO and QRMD it was observed in the storage room off the purchasing hallway that combustible materials are stored to within 18” of the sprinkler, in violation of NFPA 13-2010, 8.5.6.”

“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: 42887 Based upon documentation, fire/smoke doors are not maintained in accordance with Code requirements. Failure to maintain fire/smoke doors can result in failure of the doors to offer protection as design during an emergency event. Findings include: On July 15, 2025 at 3:30pm, while in the company of CNO and QRMD evidence of annual inspection of fire rated door assemblies and the fire rated building separation doors in accordance with Section 7.2.1.15.2 in accordance with the requirements of NFPA 80, 2010, Section 5.2, including the testing and 11-point inspection.”

“Gas and Vacuum Piped Systems - Other CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Other List in the REMARKS section any NFPA 99 Chapter 5 Gas and Vacuum Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 5 (NFPA 99) This Standard is not met as evidenced by: 42887 Based on observation, the facility failed to install and maintain the electrical and medical gas piping systems as required. This deficient practice could affect patients, staff and visitors because a failure of the electrical system could result in a fire or electric shock if an unbonded metallic pipe becomes energized. The finding is: On July 15, 2025 at 1:50pm while in the company of the QRMD, it could not be determined by direct observation that medical gas piping systems were bonded together and to the building’s grounding electrode system in accordance with NFPA 70-2011, 250.104(B).”

“Electrical Systems - Other CFR(s): NFPA 101 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 NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99) This Standard is not met as evidenced by: 42887 Based on observation, the facility failed to install and maintain the electrical system as required. This deficient practice could affect patients and staff in the Operating Room because a failure of the electrical system could result in electric shock. The findings are: A. On July 15, 2025 at 12:45pm, while in the company of the SO, CNO, and QRMD it was directly observed that the facility Conference Room contained an extension cord in use, which passed through the plane of the suspended acoustic ceiling above. This is not in accordance with NFPA 99-2012, Sections 10.2.3.6, Section 10.2.4, NFPA 70-2011, 400.8(2). B. On 7/15/25 at 1:50 p.m. while in the company of the QRMD it was observed branch circuit panels from the normal electrical system and the critical branch of the essential system were serving the Operating Room patient care vicinity with no evidence of grounding interconnects between them in accordance with NFPA 99 -2012, 6.3.2.2.3.”

“Electrical Systems - Wet Procedure Locations CFR(s): NFPA 101 Electrical Systems - Wet Procedure Locations Operating rooms are considered wet procedure locations, unless otherwise determined by a risk assessment conducted by the facility governing body. Operating rooms defined as wet locations are protected by either isolated power or ground-fault circuit interrupters. A written record of the risk assessment is maintained and available for inspection. 6.3.2.2.8.4, 6.3.2.2.8.7, 6.4.4.2 This Standard is not met as evidenced by: 42887 Based on observation, the facility failed to install and maintain the electrical system as required. This deficient practice could affect patients and staff in the building because a failure of the electrical system could result in electric shock or electrocution. The finding is: A. On July 15, 2025 at 1:40 p.m. while in the company of the QRMD, it was observed the Operating Room was not equipped with GFCI protected receptacles or an Isolated Power System in accordance with NFPA 99-2012, 6.3.2.2.8.1 and 6.3.2.2.8.4. B. On July 15, 2025 at 1:40 p.m. while in the company of the CNO and QRMD, it was observed that emergency department bay #2 contained an electrical receptacle (outlet) within six feet of a sink that was not protected by a ground fault interrupter (GFI) in accordance with NFPA 70-2010 Edition, 210.8(7).”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 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 4 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, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 42887 Based upon documentation, the Emergency Electrical System (EES) components are not maintained in accordance with Code requirements. Failure to install components in accordance with requirements can result in failure of the system to operate as intended during an emergency event. Findings include: A. On July 15, 2025 at 3:30pm, while in the company of CNO and QRMD evidence of records of weekly visual inspection of emergency generator in accordance with NFPA 110-2010 Edition, Section 8.4.1. B. On July 15, 2025 at 3:30pm, while in the company of CNO and QRMD evidence of records of monthly emergency generator exercise under load for 30 minutes with a connected minimum load of 30% of the generator’s capacity in accordance with NFPA 110-2010, Section 8-4.2. Emergency diesel generators that are not able to be exercised monthly with at least a minimum 30% load capacity can use alternate testing that include records showing the available amperage load for each phase monthly and complete a 1-1/2- hour annual load test by a generator testing service provider.”