Beaver County Memorial Hospital

“Smoke Detection CFR(s): NFPA 101 Smoke Detection 2012 EXISTING Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1. 19.3.4.5.2 This Standard is not met as evidenced by: 12713 Based on observation and interview, the facility failed to perform biannual smoke sensitivity test on smoke detectors. Without this biannual testing the facility had no assurance the smoke detectors would function as required for early detection of smoke/fire. Findings: 1. During record review on 11/07/2024, it was determined the last annual fire inspection dated 05/29/2024 did not document smoke sensitivity had been performed. The last documented smoke sensitivity was performed in 2019. 2. An interview was conducted with the maintenance supervisor on 11/07/2024 and he stated he contacted the inspection company and scheduled a sensitivity test. NFPA 72, Sec 7-3.2.1 requires that smoke detector sensitivity be checked within 1 year after installation and every alternate year thereafter.”

“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 11/07/2024. The most recent annual sprinkler inspection document was dated 05/29/2024. A quarterly sprinkler inspection should have been performed in the first quarter of 2024 and the third quarter of 2024, but no documentation was found for the two missing quarterly sprinkler inspections. 2. The maintenance supervisor was present during the record review on and stated he was not aware the quarterly sprinkler inspections had not been done.”

“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 2 of 2 smoke barrier walls to resist the passage of smoke. Findings: 1. A tour of the facility was conducted on 11/07/2024, and the following observations were made. South smoke wall a) one unsealed penetration, associated with new electrical wiring was observed above the smoke doors in the attic. West smoke wall b) one unsealed penetration, associated with new electrical wiring was observed above the smoke doors in the attic. 2. The maintenance person was present when the smoke walls were observed on 11/07/2024, and he acknowledged the unsealed penetrations to the smoke wall. Smoke barriers shall be constructed to provide at least a one half hour fire resistance rating and constructed in accordance with 8.3. Smoke barriers shall be permitted to terminate at an atrium wall. Windows shall be protected by fire-rated glazing or by wired glass panels and steel frames. 8.3, 19.3.7.3, 19.3.7.5”

“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 11/07/2024 and no documentation was found to show the facility had conducted routine corridor door inspections. 2. The facility CEO and maintenance supervisor were interviewed during the exit coference and they stated they are checking the corridor doors but they did not document. 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)”

“Fundamentals - Building System Categories CFR(s): NFPA 101 Fundamentals - Building System Categories Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. Chapter 4 (NFPA 99) This Standard is not met as evidenced by: 12713 Based on record review and interview the facility failed to ensure the building system risk assessments were completed. Findings: Record review showed the facility EES (Essential Electrical System) and Medical Gas building system risk assessments were not completed and do not exist. On 11/07/2024 the surveyor asked the CEO for the EES and Medical Gas building system risk assessments. She stated they were not aware of the requirement but would ensure they will be completed.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 12713”

“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 observation, record review and staff interview, the facility failed maintain appropriate documentation for the required monthly generator under load testing as required by NFPA 99. In the event of an electrical outage, the facility could not be assured the generator would function properly without performing the required inspections and testing. Findings: 1. The facility’s records were reviewed on 11/07/2024. No documentation was found to show the facility was performing the required monthly 30 minute under load testing of the generator. 2. The maintenance supervisor stated the generator automatically runs at times but he did not know if it ran under load for 30 minutes monthly.”