Independence Health System Clarion Hospital

“Multiple Occupancies - Construction Type CFR(s): NFPA 101 Multiple Occupancies - Construction Type Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows: * The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1 * The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters. 18.1.3.5, 19.1.3.5, 8.2.1.3 This Standard is not met as evidenced by: 42642 Based on observation and interview, the facility failed to meet multiple occupancy requirements for one of one exit door between Component 01 and Component 99. Findings include: Observation on December 11, 2025, at 11:59 a.m., revealed the first floor building separation from Component 01 to Component 99 was the direction of egress from Component 01. The fire door does not have fire exit hardware allowing push-to-open access to the exit corridor. When the doors were closed, the left door was locked from the Component 01 side. The facility was unaware if the door could be unlocked in the event of an emergency. Interview with the maintenance technician on December 11, 2025, at 11:59 a.m., confirmed the deficiency at the time of the survey.”

“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: 42642 Based on observation and interview, the facility failed to meet sprinkler system requirements on two of three building levels. Findings include: 1. Observation on December 11, 2025, between 9:10 a.m. and 11:40 a.m., revealed the sprinkler escutcheons were missing in the following locations: A (9:10 a.m.) First floor stock room; B.(10:00 a.m.) First floor ER corridor, near the exit; C. (10:47 a.m.) First floor, near X-ray 2; D. (11:40 a.m.) First floor kitchen. Interview with the maintenance technician on December 11, 2025, at 11:40 a.m., confirmed the locations were missing sprinkler escutcheons. 2. Observation on December 11, 2025, at 9:10 a.m. revealed the penthouse sprinkler line had wires taped to the sprinkler piping. Interview with the maintenance technician on December 11, 2025, at 9:10 a.m., confirmed the wires were taped to the sprinkler piping.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 43722 Based on document review and interview, the facility failed to meet requirements for HVAC systems for one of one system. Findings include: Document review on December 11, 2025, at 10:08 a.m., revealed the facility was unable to provide fire/smoke damper inspection documentation for the new ER addition of the hospital. The dampers were newly installed in 2023 and need the one-year, after-install inspection. Interview with the maintenance director on December 11, 2025, at 10:08 a.m., confirmed the facility was unable to provide the documentation. The facility is in the process of scheduling a fire/smoke damper inspection.”

“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: 42642 Based on observation and interview, the facility failed to meet requirements for maintenance, inspection, and testing of doors on one of three building levels. Findings include: Observation on December 11, 2025, at 10:03 a.m., revealed the second floor east wing fire door to delivery had multiple holes through the door. Interview with the maintenance technician on December 11, 2025, at 10:03 a.m., confirmed the deficiency at the time of the survey.”

“Electrical Systems - Receptacles CFR(s): NFPA 101 Electrical Systems - Receptacles Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover. If used in patient care room, ground-fault circuit interrupters (GFCI) are listed. 6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99) This Standard is not met as evidenced by: 42642 Based on observation and interview, the facility failed to meet electrical receptacle requirements on one of three building levels. Findings include: Observation on December 11, 2025, at 9:33 a.m., revealed the first floor OR 21 scrub room had receptacles located within six feet of the sink that were not protected by a ground fault circuit interrupter. Interview with the maintenance director on December 11, 2025, at 9:33 a.m., confirmed the deficiency at the time of the survey.”

“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: 43722 Based on document review and interview, the facility failed to meet essential electrical equipment requirements for one of two generators. Findings include: Document review on December 11, 2025, at 9:30 a.m., revealed the fuel sample, dated March 3, 2025, was rated as “action required” and required fuel polishing or filtration. The facility failed to have the deficiency corrected at the time of the survey. Interview with the maintenance director on December 11, 2025, at 9:30 a.m., confirmed the fuel sample deficiency was not corrected.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 42642 Based on observation and interview, the facility failed to meet gas equipment requirements on one of three building levels. Findings include: Observation on December 11, 2025, at 10:33 a.m., revealed the second floor corridor oxygen storage failed to have distinct separation betwen full and empty cylinders. Interview with the maintenance director on December 11, 2025, at 10:33 a.m., confirmed the deficiency at the time of the survey.”