Hopedale 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: 20224 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 February 21, 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.”

“On February 21, 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: Security Officer (SO) Maintenance Clerk (MC) The facility was observed to be Type I (332) construction, one story in height, and partially covered by an automatic sprinkler system. A wing built in 1972 has a second story containing Surgery and PACU. 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 as evidenced by the deficiencies cited under the following K-Tags.”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 20224 Based upon observation, doors required to be self-closing are held open by nonapproved means. Failure to maintain the door in the closed position or employ an approved hold-open device can compromise the safety of the means of egress for which the door separation is intended in the event of a fire/smoke condition within the space. Findings include: On 02/21/2024 while in the company of the SO and MC it was observed that hazardous area egress doors are being held open by non compliant methods 7.2.1.8.2. The example locations: A. At 11:10am door wedge used on Storage room across the corridor from Surgery Storage. B. At 11:15am door wedge used for Compactor room C. At 12:05pm door wedge used for door between Kitchen and Dining D. At 12:09pm door tie back used for Dry Good Storage door.”

“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: 20224 Based on observation, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. Failure to provide exit signs to identify exit access can prevent occupants from reaching a required exit if the primary exit is blocked by a fire/smoke condition. The finding is: On 02/21/2024 at 10:15am while accompanied by the MC exit access was observed not to be identified by exit signage located to comply with 39.2.5.2 and 7.5. Location observed: Laundry room, exit discharge door lacks an exit sign. The exit sign is place above an overhead rolling door not used for exiting.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 20224 Based on document review and staff interview the facility failed to provide documentation for the maintenance and testing of life safety systems. Failure to maintain these systems jeopardizes safety of all building occupants. The finding is: On 02/21/2024 at 12:20pm pm in the company of the SO and MC the facility failed to indicate that the kitchen hood suppression system complies with NFPA 96, 2011, 10.4.1 and 10.4.3. There is a gas fuel shut off located near the floor between the wall and the gas appliance(s). There is a box end wrench hanging from the gas pipe. The surveyor was informed that the wrench is used to shut off the gas fuel. It could not be confirmed that the suppression system will automatically shut off the gas fuel or if it is manually shut off during an emergency.”

“Fire Alarm System - Initiation CFR(s): NFPA 101 Fire Alarm System - Initiation Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse’s stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200’ travel distance is not exceeded. 18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5 This Standard is not met as evidenced by: 20224 Based on observation, not all portions of the building’s fire alarm system are installed and maintained as required. This deficient practice could affect patients, staff, or visitors in the building because the fire alarm system could fail to activate under emergency conditions if the components are not properly installed and maintained. The findings are: A. On 02/21/2024 at 10:19am while accompanied by the MC, a fire alarm manual pull station was not provided within 5’ of a designated exit. This condition does not comply with NFPA 72-2010, 17.14.6. Location observed: Laundry room exterior discharge door. B. On 02/21/2024 at 11:09am while accompanied by the MC and SO, a fire alarm manual pull station is not visible. This condition does not comply with NFPA 72-2010, 17.14.6. Location observed: Kitchen exit door leading to Dining room contains a pull station hidden from observation by an Ice Tea Dispenser.”

“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: 20224 Based on document review and staff interview the facility failed to provide documentation for the maintenance and testing of life safety systems. Failure to maintain these systems jeopardizes safety of all building occupants. The finding is: On 02/21/2024 at 12:55pm in the company of the SO and MC during review of the Fire Alarm inspection documents the vendor indicated that two manual pull stations are no longer connected to the fire alarm system. This condition provides a false sense of safety to any individual during a fire emergency should they attempt to activate the fire alarm using the disconnected device. This condition does not comply with NFPA 72, 2010 10.17. The location of the two devices was not provided within the documentation.”

“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: 20224 Based on document review and staff interview the facility failed to provide documentation for the maintenance and testing of life safety systems. Failure to maintain these systems jeopardizes of all building occupants. the finding is: On 02/21/2024 at 12:45pm accompanied by the SO and MC, Documentation was not provided which indicates that a from the floor inspection is conducted annually for sprinkler heads to comply with NFPA 25, 2011, 5.2.1.1.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 20224 Based on observation, not all corridor doors are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass into corridors if the corridor doors are not installed in a compliant manner. The finding is: On 02/21/2024 at 11:20am while accompanied by the SO and MC a corridor door did not latch to a closed position which does not comply with 19.3.6.3. Location observed: Storage room across from Surgery Storage. This door lacks a usable strike for the door latch to engage. This door simply pushes open.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and 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. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 20224 Based on document review and staff interview, the facility failed to document / conduct fire drills as required. This deficient practice could affect patients, staff and visitors if the staff failed to respond promptly during an emergency due to a lack of properly conducted fire drills. The finding is: On 02/21/2024 at 12:25pm during document review with the SO and MC, Facility fire drill documentation for the past 12 months did not indicate that requirements comply with 19.7.1. and 4.7.2. There is no indication that fire alarm components/devices are utilized during a drill due to the following: The Facility’s Fire Drill forms do not indicate the use or acitvation of a fire alarm device during any drill.”