Rural Wellness Fairfax 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 staff interview, the facility failed to maintain smoke resistant ceiling in a manner that would retard the spread of smoke to adjacent areas in the event of fire. Findings: 1. During a tour of the facility on 08/07/2024, the following observation was made: a. The ceiling of the inside mechanical room (maintenance cut through) containing gas-fired boilers and/or gas-fired water heaters, was noted to have unsealed penetrations around vent pipe and gas lines exposing the wood attic space to the hazardous areas. 2. The Plant operations supervisor was present during the entire tour of the facility on 08/07/2024 and acknowledged the unsealed penetration.”

“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 staff interview, the facility failed to maintain and test a complete automatic sprinkler system. Findings: 1. The facility records were reviewed on 08/07/2024. The most recent annual sprinkler inspection document was dated 09/11/2023. A quarterly sprinkler inspection should have been performed in the fourth quarter of 2023 and the first and second quarter of 2024. 2. The Plant Operations Supervisor and the CEO stated at the exit they were not aware of the quarterly sprinkler inspection.”

“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: 12713 Based on observation and interview, the facility failed to maintain corridor doors to resist the passage of smoke located in 1 of 3 smoke compartments. Findings: 1. A tour of the facility was conducted on 08/07/2024 and the following observation was made: a. The Emergency Room #1 had a roller latch to keep the door closed. 2. The Plant Operations supervisor was present during the tour of the facility and acknowledged the roller latch on the door of ER #1. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9 This Standard is not met as evidenced by: 12713 Based on observations and staff interview, the facility failed to maintain smoke barrier doors on 1 of 3 halls to close properly to resist the passage of smoke. Findings: 1. The smoke barrier doors between the ER and the lab area were test on 08/07/2024. These set of doors did not properly close and seal to resist the passage of smoke. 2. The Plant Operations Supervisor was present during the testing of the smoke doors and he stated he would get the doors fixed.”

“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: 12713 Based on record review and interview, the facility failed to conduct the routine inspections of the corridor doors throughout the facility. Findings 1. The facility records were reviewed on 08/07/2024 and no documentation was found to show the facility had conducted routine corridor door inspections. 2. The Plant Operations Supervisor was interviewed during the record review and he stated they do routine inspections on all doors, but they did not document the inspections. Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protective’s. 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)”

“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: 12713 Based on record review and staff interview, the facility failed to conduct weekly generator inspections and testing of the generator battery as required by NFPA 99. In the event of an electrical outage, the facility could not be assured the generator would function properly. Findings 1. The facility’s records were reviewed on 08/07/2024. No documentation was found to show the facility had performed the weekly generator inspection and battery electrolyte testing for the past year. 2. The Plant Operations Supervisor was interviewed during the paper review on 08/07/2024 and he stated they have not been documenting the weekly inspection.”

“LICENSURE, CERT., OR REG OF PERSONNEL CFR(s): Staff of the CAH are licensed, certified, or registered in accordance with applicable Federal, State, and local laws and regulations. This Standard is not met as evidenced by: 41505 Based upon record review and interview the hospital failed to ensure licensure and/or registration of staff was current. This was evidenced by review of 1 of 8 (Staff L) employee files and 4 of 8 (Staff M, N, O P) contract employee files. Findings: Review of the personnel file for Staff L, a Respiratory Therapist, revealed the licensure had expired on 08/31/23. Review of contract therapist employees revealed the following: Staff N, Occupational Therapy Assistant, licensure expired 10/31/23, Staff O , Occupational Therapy Assistant, licensure expired 10/31/22, Staff P, Physical Therapy Assistant licensure expired 01/31/22. Review of the personnel file for contract Staff M revealed there failed to be evidence the licensure and/or Registration was verified. Interview on 06/28/24 at 2:20 p.m. with Staff E revealed she was not aware the licensure and/or registration of hospital staff and contract staff had expired.”