Harper County Community Hospital

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 12713 Based on observation and interview, the facility failed to maintain smoke resistant walls in a manner that would retard the spread of smoke to adjacent areas in the event of fire in hazardous areas located in 1 of 1 mechanical room. Findings: On 08/06/26 between 10:20 a.m. and 1:40 p.m. a tour of the facility was conducted and the following observation was made: a. The mechanical room housed a gas-fired furnace and gas fired water heater had unsealed penetrations in the walls around water lines and refrigeration lines. On 08/06/26 at 11:20 a.m. the director of nursing was present during the tour of the mechanical room and acknowledged the problems with the hazardous area.”

“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: 12713 Based on record review and interview, the facility failed to maintain and test a complete automatic sprinkler system. Findings: On 08/06/26 at 10:50 a.m. the facility records were reviewed. The most recent annual sprinkler inspection document was dated 05/14/25. The next annual sprinkler inspection should have been performed on or before 05/14/26. No documentation was found to show a current annual sprinkler inspection had been performed. On 08/06/26 at 10:55 a.m. the director of nursing was present during the record review and stated the company had not completed the annual inspection.”

“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: 12713 Based on observation and interview, the facility failed to maintain 1 of 1 smoke barrier walls to resist the passage of smoke. Findings: On 08/06/26 between 10:20 a.m. and 1:40 p.m. a tour of the facility was conducted, and the following observation was made. a. one unsealed penetration associated with a coax wires and computer wires were observed above the smoke doors in the attic. On 08/06/26 at 12:10 p.m. the director of nursing was present when the smoke wall was observed and acknowledged the unsealed penetrations to the smoke wall.”

“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: 12713 Based on observation and interview, the facility failed to properly maintain a remotely located emergency stop kill switch for the generator. Findings: On 08/04/26 at 11:20 a.m., a tour of the facility’s generator was conducted. The generator was not equipped with a remotely located emergency stop kill switch to assure the generator could be powered down remotely in the event of a generator fire/emergency. On 08/04/26 at 11:25 p.m., the director of nursing was interviewed and acknowledged the generator was not equipped with the required remote emergency stop kill switch.”

“Contracted Services. CFR(s): (b)The governing body must be responsible for services furnished in the REH whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the REH to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 42140 Based on observation and interview, the facility failed to ensure evaluation of contracted service for one (company name withheld) of two contracted services reviewed. On 07/15/26 at 3:48 pm, the SQSS was observed and did not show an evaluation for (company name withheld). On 07/15/26 at approximately 11:15 am, Staff E stated (company name withheld) performed preventative maintenance on medical equipment. On 07/15/26 at 3:48 pm, Staff F stated: 1. Evaluations were completed in SQSS 2. (Company name withheld) was not in SQSS. 3. There was no evaluation of the service for (company name withheld.”

“Contracted Services. CFR(s): (b)(2) The REH must maintain a list of all contracted services, including the scope and nature of the services provided. This Standard is not met as evidenced by: 42140 Based on observation, record review and interview, the facility failed to ensure comprehensive listing of contracted services for two (online and paper) listings reviewed. On 07/15/26 at 3:48 pm, the SQSS was observed and did not show (company name withheld) in the list of contracted services. Review of a document titled “Harper County Community Hospital List of Contractor providing Services” dated March 2026 did not show (company name withheld). On 07/15/26 at 3:48 pm, Staff F stated: 1. (Company name withheld) was not on the document or in SQSS. 2. The facility had a contract in place with (company name withheld) for at least seven years.”