Independence Health System Butler Memorial Hospita

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 43722 Based on observation and interview, the facility failed to maintain the means of egress, being free of all obstructions, for one of over five exits within this facility. Findings include: Observation on October 23, 2024, at 10:26 a.m., revealed the second floor cardiac cath lab exit corridor, next to S-2 stairwell, was obstructed with multiple carts. Interview with the maintenance technician on October 23, 2024, at 10:26 a.m., confirmed the exit discharge was obstructed.”

“Vertical Openings - Enclosure CFR(s): NFPA 101 Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box. This Standard is not met as evidenced by: 43722 Based on observation and interview, the facility failed to maintain vertical openings for one of over four chute doors. Findings include: Observation on October 23, 2024, at 12:33 p.m., revealed the fourth floor, south wing, soiled linen chute door failed to properly close and self-latch. Interview with the maintenance technician on October 23, 2024, at 12:33 p.m., confirmed the chute door deficiency. 49939 Based on observation and interview, the facility failed to maintain vertical door openings for two of two vertical door openings. Findings include: Observation on October 23, 2024, between 12:12 p.m. and 12:35 p.m., revealed the following vertically opening doors failed to properly close and self-latch: A. (12:12 p.m.) Three X, three north, third floor, soiled linen room, chute door; B. (12:35 p.m.) Three X, three south, third floor, soiled linen room, chute door. Interview with the operations manager on October 23, 2024, at 12:35 p.m., confirmed the vertical door deficiencies.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 42642 Based on observation, document review, and interview, the facility failed to meet ANSI/UL 300 requirements for one of one cooking facility. Findings include: Observation on October 23, 2024, at 1:40 p.m., revealed the cooking facility failed to have automatic extinguishing equipment that met UL 300 systems using wet chemicals. The facility had the first layer of protection by a wet pipe sprinkler system. Upon investigation, the kitchen was occasionally cooking using oil. A buildup of black sludge covered one silver sprinkler head over the grill. The sludge may limit the sprinkler’s ability to work properly in the event of an emergency. In addition, the facility failed to provide proper placard signage to meet NFPA 96 10.2.2 requirements, identifying the second layer of extinguishment protection of the K-type fire extinguisher. Interview with the director of facilities on October 23, 2024, at 1:40 pm., confirmed the deficiencies and stated the facility is in the process of replacing the system.”

“Alcohol Based Hand Rub Dispenser (ABHR) CFR(s): NFPA 101 Alcohol Based Hand Rub Dispenser (ABHR) ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met: * Corridor is at least 6 feet wide * Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols * Dispensers shall have a minimum of 4-foot horizontal spacing * Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room * Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30 * Dispensers are not installed within 1 inch of an ignition source * Dispensers over carpeted floors are in sprinklered smoke compartments * ABHR does not exceed 95 percent alcohol * Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11) * ABHR is protected against inappropriate access 18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485 This Standard is not met as evidenced by: 42642 Based on observation and interview, the facility failed to meet alcohol-based hand rub requirements for one of three components. Findings include: Observation on October 23, 2024, at 11:20 a.m., revealed the pharmacy storage room had over 30 gallons of 200-proof, 100% alcohol hand sanitizer stored in boxes in a single smoke compartment. Interview with the regional facilities director on October 23, 2024, at 11:20 a.m., confirmed the alcohol-based hand sanitizer stored exceeded quantity requirements.”

“Fire Alarm System - Installation CFR(s): NFPA 101 Fire Alarm System - Installation A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8 This Standard is not met as evidenced by: 42642 Based on observation and interview, the facility failed to meet fire alarm system requirements for one of over three fire alarm panels. Findings include: Observation on October 23, 2024, at 11:10 a.m., revealed first floor electrical closet 1 main ADD 15, outside of the pharmacy, had a fire alarm panel that was not functioning. No information was provided to indicate the panel was outdated or still in use. Interview with the facilities regional director on October 23, 2024, at 11:10 a.m., confirmed the fire alarm panel was not functioning.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 42642 Based on observation and interview, the facility failed to maintain the fire alarm system, affecting the main building. Findings include: Observation on October 23, 2024, at 11:22 a.m., revealed the fire alarm panel displayed multiple trouble signals. Through interview, the trouble mode was bypassed due to approved construction activities at the facility. The facility did not want the construction to inadvertently activate the alarm system. The alarm panel is still monitored by the facility dispatch center. Interview with the director of facilities on October 23, 2024 at 11:22 a.m., confirmed the fire alarm panel deficiency.”

“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 document review and interview, the facility failed to meet sprinkler system requirements for one of three components. Findings include: Document review on October 23, 2024, at 9:32 a.m., revealed the last annual fire pump inspection occurred on September 7, 2023. Interview with the facilities director on October 23, 2024, at 9:32 a.m., confirmed the facility lacked documentation for a more-recent inspection, and stated a vendor was scheduled to complete the inspection soon. 43722 Based on observation and interview, the facility failed to maintain the sprinkler system in one of three components. Findings include: Observation on October 23, 2024, at 9:30 a.m., revealed the seventh floor S main 7 stairwell had a sprinkler gauge with a 2015 date, without documentation that calibration took place within the last five years. Interview with the maintenance technciain on October 23, 2024, at 9:30 a.m., confirmed the sprinkler gauge deficiency.”

“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: 49939 Based on observation and interview, the facility failed to maintain the smoke barrier requirements in two of over ten rooms. Findings include: Observation on October 23, 2024, between 8:59 a.m. and 9:07 a.m., revealed the following deficiencies: A. (8:59 a.m.) Ground floor corridor connecting to the new addition, near door 36, had two penetrations in the wallboard; B. (9:07 a.m.) Ground floor electrical room had cinderblock and wall joint openings, allowing smoke passage. Interview with the maintenance supervisor on October 23, 2024, at 9:07 a.m., confirmed the smoke barrier deficiencies.”

“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: 42642 Based on document review and interview, the facility failed to meet fire drill requirements for three of three components. Findings include: Document review on October 23, 2024, at 9:44 a.m., revealed the facility lacked documentation for incorporating fire drills with all staff members each shift, per quarter. Interview with the facility director on October 23, 2024, at 9:44 a.m., confirmed the facility lacked the documentation.”

“Combustible Decorations CFR(s): NFPA 101 Combustible Decorations Combustible decorations shall be prohibited unless one of the following is met: o Flame retardant or treated with approved fire-retardant coating that is listed and labeled for product. o Decorations meet NFPA 701. o Decorations exhibit heat release less than 100 kilowatts in accordance with NFPA 289. o Decorations, such as photographs, paintings and other art are attached to the walls, ceilings and non-fire-rated doors in accordance with 18.7.5.6(4) or 19.7.5.6(4). o The decorations in existing occupancies are in such limited quantities that a hazard of fire development or spread is not present. 19.7.5.6 This Standard is not met as evidenced by: 49939 Based on observation and interview, the facility failed to maintain combustible decorations on seven of over fourteen doors. Findings include: Observation on October 23, 2024, at 12:32 p.m., revealed building three X, third floor, three south, had seven doors with decorations that exceeded the allowable rate of coverage (= thirty percent). Interview with the maintenance supervisor on October 23, 2024, at 12:32 p.m., confirmed the combustible decoration deficiencies.”

“Soiled Linen and Trash Containers CFR(s): NFPA 101 Soiled Linen and Trash Containers Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gallons/square feet. A total container capacity of 32 gallons shall not be exceeded within any 64 square feet area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons shall be located in a room protected as a hazardous area when not attended. Containers used solely for recycling are permitted to be excluded from the above requirements where each container is less than or equal to 96 gallons unless attended, and containers for combustibles are labeled and listed as meeting FM Approval Standard 6921 or equivalent. 18.7.5.7, 19.7.5.7 This Standard is not met as evidenced by: 49939 Based on observation and interview, the facility failed to manage quantities of soiled linen/trash in approved containers in one of more than seven soiled linen/trash rooms. Findings include: Observation on October 23, 2024, at 9:10 a.m., First floor, soiled linen/trash room, chute discharge area, revealed excessive amounts, and overflowing trash bins onto the floor and not in approved containers, from the trash discharge of the trash chute. Plastic bags and loose trash was on the floor, creating a fire hazard. Interview with the maintenance supervisor on October 23, 2024, at 9:10 a.m., confirmed the deficiency.”

“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 document review and interview, the facility failed to meet door maintenance, inspection, and testing requirements for three of three components. Findings include: Document review on October 23, 2024, at 10:00 a.m., revealed the facility’s 2023 and 2024 inspection reports listed multiple doors that were not inspected due to access issues and multiple doors with deficiencies. The facility lacked corrective documentation at the time of the survey. Interview with the facility director on October 23, 2024, at 10:00 a.m., confirmed the facility lacked corrective documentation.”

“Gas and Vacuum Piped Systems - Inspection and CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Inspection and Testing Operations The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required. 5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99) This Standard is not met as evidenced by: 42642 Based on document review and interview, the facility failed to meet gas and vacuum-piped system requirements for one of one system. Findings include: Document review on October 23, 2024, at 9:01 a.m., revealed the following system deficiencies were documented on the April 24, 2024, inspection report. Corrective documentation was unavailable at the time of the survey: Outlets/Inlets A. Seventh floor, med surg - medical vacuum, W#2 bent faceplate; B. Seventh floor, med surg - oxygen, leak with the connector in; C. Third floor, OR 10 - nitrogen, CB#1 regulator knob broken; D. First floor, OR 3 - medical vacuum, medpipe boom service to further investigate low flow; E. Third floor, OR7- nitrogen, cb31 - N2 regulator knob missing; F. Third floor, peri op room 6- oxygen, CO#1 faceplate replacement required. Interview with the facilities director on October 23, 2024, at 9:01 a.m., confirmed the facility lacked corrective documentation.”

“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: 42642 Based on observation and interview, the facility failed to meet electrical system requirements in one of over ten storage rooms. Findings include: Observation on October 23, 2024, at 11:00 a.m., revealed the first floor storage room, located across from the lab window entrance, had blocked access to electrical panel “UPS C”. Reference: 70-110.26(A) Interview with the facility regional director on October 23, 2024, at 11:00 a.m., confirmed access to the electric panel was blocked.”

“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: 49939 Based on observation and interview, the facility failed to maintain two of more than twenty electrical receptacles. Findings include: Observation on October 23, 2024, between 12:36 p.m. and 12:38 p.m., revealed the facility could not verify that ground fault circuit interrupter (GFCI) receptacles were installed in the following locations: 1. (12:36 p.m.) Three south, third floor, clean utility room, receptacle within six feet of the sink; 2. (12:38 p.m.) Three south, third floor, laundry room, washing machine. Interview with the maintenance supervisor on October 23, 2024, at 12:38 p.m., confirmed the electrical outlet deficiencies.”

“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: 49939 Based on observation and interview, the facility failed to maintain electrical power cords in one of over twenty rooms. Findings include: Observation on October 23, 2024, at 12:19 p.m., revealed the three X, three north, third floor employee lounge had a microwave oven plugged into a surge protector power strip. Interview with the maintenance supervisor on October 23, 2024, at 12:19 p.m., confirmed the power cord deficiency.”

“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: 49939 Based on observation and interview, the facility failed to maintain gas equipment storage requirements in one of four cylinder storage areas. Findings include: Observation on October 23, 2024, at 9:59 a.m., revealed the Tower building first-floor oxygen storage room, located near the chapel and outpatient nutritional room, contained six oxygen cylinders without quantity labeling. Interview with the maintenance supervisor on October 23, 2024, at 9:59 a.m., confirmed the deficiency.”