Fulton County Medical Center

“Facility ID# 061901 Component 11 New Outpatient Building Based on an unannounced Medicare Recertification Survey completed on December 10, 2024, it was determined that The Fulton County Medical Center New Outpatient Building, a satellite component of The Fulton County Medical Center was not in compliance with the requirements of the Life Safety Code for a New critical access health care occupancy. Compliance with the National Fire Protection Association’s Life Safety Code is required by 42 CFR 485.623(d). This is a one-story, Type II (111), protected non-combustible building, without a basement, that is fully sprinklered.”

“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: 41378 Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in three instances, affecting two of eleven smoke compartments. Findings include: 1. Observation on December 9, 2024, revealed the following hazardous area enclosure deficiencies: a) 10:54 the receiving room door was being held open with an unapproved hold-open device (wooden wedge); b) 10:55 a.m., the receiving room door was unable to self-close and latch in its frame when tested; c) 11:04 a.m., revealed the purchasing room door equipped with an astragal, which prevented the inactive door from closing and latching before the active door closes and latches, coordinating devices shall be used. In accordance with NFPA 80, 2010 Edition, 6.4.1.2 and 6.4.1.2.1. Interview with the Facility COO, Maintenance Supervisor, and Facility Staff on December 10, 2024, at 1:30 p.m., confirmed the listed hazardous area enclosure 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: 41378 Based on observation and interview, it was determined the facility failed to maintain cooking equipment from unauthorized use in one instance, affecting one of eleven smoke compartments. Findings include: 1. Observation on December 9, 2024, at 11:52 a.m., revealed a residential type of range without a lock-out switch/device, was in the OT department. Interview with the Facility COO, Maintenance Supervisor, and Facility Staff on December 10, 2024, at 1:30 p.m., confirmed the listed cooking equipment deficiency.”

“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: 41378 Based on documentation review and interview, it was determined the facility failed to perform the required inspections of the automatic fire alarm system in two instances, affecting the entire facility. Findings Include: 1. Review of documentation on December 10, 2024, at 10:00 a.m., revealed the facility could not provide documentation for the following required testing of the automatic fire alarm system, to be performed within the past twelve months: a) annual functional test of the automatic fire alarm system; b) semi-annual visual inspection of the automatic fire alarm system. Interview with the Facility COO, Maintenance Supervisor, and Facility Staff on December 10, 2024, at 1:30 p.m., confirmed the facility failed to provide documentation for the fire alarm system testing, at the time of the survey.”

“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: 41378 Based on documentation review and interview, it was determined the facility failed to perform the required inspections of the automatic fire alarm system in two instances, affecting the entire facility. Findings Include: 1. Review of documentation on December 10, 2024, at 10:00 a.m., revealed the facility could not provide documentation for the following required testing of the automatic fire alarm system, to be performed within the past twelve months: a) annual functional test of the automatic fire alarm system; b) semi-annual visual inspection of the automatic fire alarm system. Interview with the Facility COO, Maintenance Supervisor, and Facility Staff on December 10, 2024, at 1:30 p.m., confirmed the facility failed to provide documentation for the fire alarm system testing, 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: 41378 Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in eight instances, affecting six of eleven smoke compartments. Findings include: 1. Observation on December 9, 2024, revealed the facility failed to maintain a heat/smoke resistive ceiling for the proper activation/operation of the automatic sprinkler system in the following locations: a) 10:14 a.m., there were multiple unsealed conduit penetrations in the ceiling of electrical closet number seven in acute care; b) 10:30 a.m., there were unsealed dryer vent pipes in the ceiling of the personal laundry; c) 10:41 a.m., there were multiple unsealed pipe penetrations in the ceiling of the MDF room; d) 10:50 a.m., there was an unsealed penetration in the ceiling of the café above the refrigerator; e) 11:24 a.m., there were unsealed exhaust vent pipes in the ceiling of the lab above the chemistry analyzers; f) 11:25 a.m., there was an unsealed data wire in the ceiling of the lab in the plenix area; g) 12:45 p.m., there were misaligned ceiling tiles in the cardiology nurse station. Interview with the Facility COO, Maintenance Supervisor, and Facility Staff on December 10, 2024, at 1:30 p.m., confirmed the listed automatic sprinkler system deficiencies. 2. Observation on December 9, 2024, at 1:00 p.m., revealed the facility failed to maintain storage below the eighteen-inch horizontal sprinkler plane in the storage room located in the aerobics area of the wellness center. Interview with the Facility COO, Maintenance Supervisor, and Facility Staff on December 10, 2024, at 1:30 p.m., confirmed the storage interfered with automatic sprinkler system coverage.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 41378 Based on observation and interview, it was determined that the facility failed to maintain portable fire extinguishers in three instances, affecting three of eleven smoke compartments. Findings include: 1. Observation on December 9, 2024, revealed the following portable fire extinguisher deficiencies: a) 10:40 a.m., there was an unsecured portable fire extinguisher in the MDF room; b) 10:56 a.m., access to the portable fire extinguisher at the outside exit door by the receiving room was blocked by miscellaneous storage; c) 12:33 p.m., there was an unsecured portable fire extinguisher in the MRI equipment room. Interview with the Facility COO, Maintenance Supervisor, and Facility Staff on December 10, 2024, at 1:30 p.m., confirmed the listed portable fire extinguisher deficiencies.”

“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: 41378 Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator monthly testing in one instance, affecting the entire facility. Findings include: 1. Review of documentation. December 10, 2024, at 10:00 a.m., revealed the facility could not provide monthly conductance test documentation for the emergency generator batteries for September, October, and November of 2024. Interview with the Facility COO, Maintenance Supervisor, and Facility Staff on December 10, 2024, at 1:30 p.m., confirmed the missing emergency generator testing documentation.”

“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: 41378 Based on observation and interview, it was determined the facility failed to maintain the emergency generator enclosure as a non-storage area, in one instance affecting one of 11 smoke compartments. Maintenance shall be in accordance with NFPA 110, 7.2.1.2 Findings include: 1. Observation on December 9, 2024, at 11:08 a.m., revealed the emergency generator room was being used to store miscellaneous items unrelated to the maintenance of the emergency generator. Interview with the Facility COO, Maintenance Supervisor, and Facility Staff on December 10, 2024, at 1:30 p.m., confirmed the listed emergency generator room deficiency. Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator monthly testing in one instance, affecting the entire facility. Findings include: 2. Review of documentation. December 10, 2024, at 10:00 a.m., revealed the facility could not provide monthly conductance test documentation for the emergency generator batteries for September, October, and November of 2024. Interview with the Facility COO, Maintenance Supervisor, and Facility Staff on December 10, 2024, at 1:30 p.m., confirmed the missing emergency generator testing documentation.”

“Electrical Equipment - Other CFR(s): NFPA 101 Electrical Equipment - Other List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, 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 10 (NFPA 99) This Standard is not met as evidenced by: 41378 Based on observation and interview, it was determined the facility failed to maintain electrical equipment in one instance, affecting one of eleven smoke compartments, per NFPA 99 2012 Edition, Chapter 10.1.1 Findings include: 1. Observation on December 9, 2024, at 11:58 a.m., revealed access to the electrical panels in the I Care Lounge storage room was blocked by miscellaneous storage items. Interview with the Facility COO, Maintenance Supervisor, and Facility Staff on December 10, 2024, at 1:30 p.m., confirmed the listed electrical equipment deficiency.”

“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: 41378 Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in one instance, affecting one of eleven smoke compartments. Findings include: 1. Observation on December 9, 2024, at 10:23 a.m., revealed there was a power strip plugged into an extension cord in electrical closet number six. Interview with the Facility COO, Maintenance Supervisor, and Facility Staff on December 10, 2024, at 1:30 p.m., confirmed the listed electrical wiring systems 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: 41378 Based on observation and interview, it was determined the facility failed to maintain medical gas storage requirements in one instance, affecting one of eleven smoke compartments Findings include: 1. Observation on December 9, 2024, at 10:33 a.m., revealed there was an unsecured oxygen cylinder in the LTC gym. Interview with the Facility COO, Maintenance Supervisor, and Facility Staff on December 10, 2024, at 1:30 p.m., confirmed the listed medical gas storage deficiency.”