Lawrence County 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: 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 August 25 - 26, 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 August 25 - 26, 2025 the Life Safety Code portion of the recertification survey was conducted The surveyor was accompanied during the survey walk-through by the facility’s: E-1 Maintenance Director E-2 Corporate Compliance/Risk Manager E-3 Director of Emergency Preparedness E-4 Chief Executive Officer E-5 Chief Financial Officer The facility consists of multiple buildings. The buildings are described as: The Original Building - Building #1 The Emergency Department Addition - Building # 2 The Surgery Addition - Building # 3 The Original Building is partially sprinklered and is construction type I (332). It is two stories with a basement. The Original Building 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 2010). Unless otherwise noted, all deficiencies cited herein were found through random 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 - 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 08/25/25 at 12:55 PM, 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 08/25/25 at 12:55 PM, 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, in accordance with NFPA 101, 2012 Edition, Section 9.6.1.6. 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. The Illinois Department of Public Health, Springfield, (the 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 includes the following: (1) The personnel conducting the fire watch have no other duties. (2) Training records of staff conducting the fire watch for notification procedures, extinguishment training and fire prevention. (3) Identification of Staff performing the Fire Watch (4) Access to all spaces provided to Fire Watch Staff (keys), except medication storage rooms where access will be provided by nursing staff. These findings were reviewed at the Exit Conference with E-1, E-2, E-3, E-4 and E-5.”

“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 08/25/25 at 1:15 PM, during review of the Sprinkler System Inspection Reports with E-1 and E-2, 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. Examples of missing inspections include: 1. 1st Quarter 2025 2. 4th Quarter 2024 B. On 08/25/25 at 1:15 PM, Document review with E-1 revealed the facility failed to provide records, for monthly inspections of the wet sprinkler pressure gauges in accordance with NFPA 25, 2011 Edition Section 5.2.4.1, Section 5.1.1.2 and Table 5.1.1.2. These findings were reviewed at the Exit Conference with E-1, E-2, E-3, E-4 and E-5.”

“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 08/25/25 at 12:55 PM, 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 08/25/25 at 12:55 PM, 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, of 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, and shall include the following: (1) The personnel conducting the fire watch has no other duties (2) Training records of staff conducting the fire watch for notification procedures, extinguishment training and fire prevention. (3) Identification of Staff performing the Fire Watch (4) Access to all spaces provided to Fire Watch Staff (keys), except medication storage rooms where access will be provided by nursing staff. 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) Supervisors are notified (2) Property Owner or designated representative, Insurance Carrier, Alarm Company, IDPH and other AHJs are notified (3) Impairment tags removed. These findings were reviewed at the Exit Conference with E-1, E-2, E-3, E-4 and E-5.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 45539 Based on an observation, it was revealed that the facility failed to provide properly constructed smoke barrier walls to meet at least 30 minutes fire resistance rating. This deficiency to the smoke barrier could affect all patients in the building 0103 - Room 1013 - IT Closet, as well as an indeterminable number of staff and visitors, if smoke or fire was allowed to pass from one smoke compartment to another. Findings include: On 08/26/25 at 1:29 PM, while accompanied by E-1, an observation revealed that the building 0103 - Room 1013 - IT Closet Smoke Barrier Wall is deficient above the lay-in ceiling, as visible from the IT Closet side of the barrier. There was one (1) three-quarter inch (3/4-inch) plastic pipe penetrating the wall with one (1) wire running through it. The pipe was not fire-stopped with a system listed by Underwriters laboratory (UL) or any other recognized testing agency. There was one (1) three-inch hole in the wall with a bundle of network cables running through it. The opening was not fire-stopped with a system listed by Underwriters laboratory (UL) or any other recognized testing agency. These were not in accordance with NFPA 101; 2012 Edition, Sections 8.3.2; 8.3.6.1 and 19.3.7.3. This finding was reviewed at the Exit Conference with E-1, E-2, E-3, E-4 and E-5.”

“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: 45539 Based on document review it was revealed that the facility failed to conduct fire drills as required. Fire drills are to be held at unexpected times under varying conditions, at least quarterly on each shift. This deficient practice could affect all patients, in all Smoke Zones, as well as an indeterminable number of staff and visitors if they do not know how to evacuate the building or smoke zone in a fire emergency due to the lack of training Findings include: On 08/25/25 at 2:43 PM, during review of the facility’s Fire Drills it was revealed that the facility had no documentation that the Fire Alarm monitoring company was contacted after all the required fire drills to ensure a signal was sent. This did not meet the requirements of LSC; Section 19.7.1.4. 1. 07/30/25 - Day Shift 2. 06/30/25 - Night Shift 3. 05/30/25 - Evening Shift This finding was reviewed at the Exit Conference with E-1, E-2, E-3, E-4 and E-5.”

“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: 45539 Based on a document review and an interview, the facility failed to provide required documentation for the generators’ operation. This deficient practice could affect all patients in all Smoke Zones, as well as an indeterminable number of staff and visitors, if the generators failed to operate as required due to the lack of routine maintenance. Findings include: A. On 08/25/25 at 3:23 PM, during review of the Generator Log and Maintenance Schedule and an interview with E-1, it was revealed that the facility failed to document and log the required transfer time of the load transfer to the Generator Sets, on the monthly Generator Exercise Logs and was not per NFPA 99, 2012 Edition, Section 6.5.3.1. B. On 08/25/25 at 3:23 PM, during review of the Generator Log and Maintenance Schedule it was revealed that the facility failed to document and log the required 5-minute cool down time of the load transfer from the Generator Sets during the monthly Generator Exercise Logs and was not per NFPA 110, 2010 Edition, Section 8.4.5. These findings were reviewed at the Exit Conference with E-1, E-2, E-3, E-4 and E-5.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 45539 Based on observations the facility failed to install electrical wiring to ensure the safety of the staff and patients. This deficient practice could affect all patients in all Smoke Zones, as well as an indeterminable number of staff and visitors, if the electrical wiring started a fire from overloading electrical circuits or electrical shock occurred due to the failure. Findings include: A. On 08/26/25 at between 12:27 PM and 1:16 PM, while accompanied by E-1, observations revealed that offices throughout the facility were using surge-protected power strips, in lieu of fixed wiring, to power non-sensitive electrical equipment. The power strips were lying on the floor where they could pose tripping hazards and were not attached to the wall in accordance with NFPA 70; 2011 Edition, Section 400.8 and CMS S & C Memo 14-46-LSC. Examples of offices with surge-protected power strips include: 1. Building 0103 - Office 1016 2. Building 0103 - Office 1052 3. Building 0103 - Office 1037 B. On 08/26/25 at 12:55 PM, while accompanied by E-1, observation revealed that the Building 0103 - Room 1010 was using a surge-protected power strip and an extension cord to operate electronic equipment. Flexible cables (extensions cords) shall not be as a substitute for the fixed wiring of a structure in accordance with the NFPA 70; 2011 Edition, Section 400.8 and the CMS 100-7 State Operations Providers Certification. C. On 08/26/25 at 12:56 PM, while accompanied by E-1, an observation revealed that the Building 0103 - Room 1052, was using a surge-protected power strip, in lieu of fixed wiring, to power non-sensitive electrical equipment including a refrigerator and a coffee maker and was not attached to the wall in accordance with NFPA 70; 2011 Edition, Section 400.8 and CMS S & C Memo 14-46-LSC. These findings were reviewed at the Exit Conference with E-1, E-2, E-3, E-4 and E-5.”