SUMMARY PROVER'S PLAN OF CORRECTION K 000 INITIAL COMMENTS K 000 A Life Safety Code Survey was conducted by the State Fire Marshal beginning on May 9th, 2017 and ending on May 10th, 2017. Adair Acute Care was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 482.41, Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101-2012 edition. Adair Acute Care is located at the Osawatomie State Hospital Campus at 500 State Hospital Drive. This facility was constructed in 1958 and is in a type II (111) building. The building is fully protected by a wet sprinkler system. There is smoke detection in all corridors, rooms, and spaces open to the corridor. The facility does not have cooking equipment located in this building. There is one smoke barrier separating the building into two smoke zones. All corridors and patient rooms have fire rated plywood ceilings. The facility utilizes keyed locks on all exit doors from the building. Every staff member has this key on their person at all times. Everyone pull station and fire extinguisher cabinet is also locked, with all staff members having keys to gain access to them. K 281 The facility has a capacity of 60. At the time of the survey the census was 45. NFPA 101 Illumination of Means of Egress Illumination of Means of Egress Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and K 281 6/10/17 LABORATORY DIRECTOR'S OR PROVER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. 05/19/2017 Event : KNFH21 Facility : H061002 If continuation sheet Page 1 of 23
SUMMARY PROVER'S PLAN OF CORRECTION K 281 Continued From page 1 K 281 shall be either continuously in operation or capable of automatic operation without manual intervention. 18.2.8, 19.2.8 This STANDARD is not met as evidenced by: Based on observation and staff interview the facility failed to provide continuous illumination of exit discharges within all exits from the building to values of at least 1 ft. candle (10 lux) measured at the floor. This deficient practice does not insure that exit discharge path will be illuminated continuously and will delay egress, affecting all residents in two of two smoke zones. The facility has a capacity of 60 with a census of 45 at the time of survey. Findings include: During the survey on May 9th, 2017 the following is observed: 1. At 2:00 p.m. it is observed that every exterior light from the building is illuminated by a light fixture with a single bulb. The Chief Operating Officer, maintenance director and safety/security chief were present during the survey and acknowledged the findings. Illumination of Means of Egress. Means of egress shall be illuminated in accordance with Section 7.8. 2012 NFPA 101, 19.2.8 Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use, unless otherwise provided in Event : KNFH21 Facility : H061002 If continuation sheet Page 2 of 23
SUMMARY PROVER'S PLAN OF CORRECTION K 281 Continued From page 2 K 281 K 321 7.8.1.2.2. The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated in 7.8.1.1 shall be illuminated as follows: (1) During conditions of stair use, the minimum illumination for new stairs shall be at least 10 ft-candle (108 lux), measured at the walking surfaces. (2) The minimum illumination for floors and walking surfaces, other than new stairs during conditions of stair use, shall be to values of at least 1 ft-candle (10.8 lux), measured at the floor. (3) In assembly occupancies, the illumination of the walking surfaces of exit access shall be at least 0.2 ft-candle (2.2 lux) during periods of performances or projections involving directed light. (4) The minimum illumination requirements shall not apply where operations or processes require low lighting levels. Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2.2 lux) in any designated area. 2012 NFPA 101, 7.8.1.2 through 7.8.1.4 NFPA 101 Hazardous Areas - Enclosure Hazardous Areas - Enclosure 2012 EXISTING 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. 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 K 321 6/10/17 Event : KNFH21 Facility : H061002 If continuation sheet Page 3 of 23
SUMMARY PROVER'S PLAN OF CORRECTION K 321 Continued From page 3 K 321 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 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: Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other spaces. The area of deficient practice would provide a path for smoke and fire to travel into the adjacent area, affecting two of two smoke zones. The facility has a capacity of 60 with a census of 45 at the time of survey. Findings include: During the survey on May 9th, 2017 the following is observed : 1. At 1:45 p.m. in the main mechanical room located in the building 1 side there is an approximate 1 inch gap around all four sides of duct work in the separation wall from the corridor. 2. At 2:55 p.m. there is a 1 inch unsealed gap where the drywall meets the roof deck in the Event : KNFH21 Facility : H061002 If continuation sheet Page 4 of 23
SUMMARY PROVER'S PLAN OF CORRECTION K 321 Continued From page 4 K 321 separation wall between the building 2 side storage room and the corridor. This is located above the ceiling in the corridor. 3. At 3:00 p.m. there is an approximate 1 inch unsealed gap where the drywall meets the roof deck in the separation wall between room 163 and the storage room. This is located above the ceiling inside room 163 on the building 1 side. There is also a 2inch by inch unsealed hole in this same wall that a piece of flex conduit is passing through. The Chief Operating Officer, maintenance director and safety/security chief were present during the survey and acknowledged the findings. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. 2012 NFPA 101, 19.3.2.1 An automatic extinguishing system, where used in hazardous areas, shall be permitted to be in accordance with 19.3.5.9. 2012 NFPA 101, 19.3.2.1.1 Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4. 2012 NFPA 101, 19.3.2.1.2 K 354 NFPA 101 Sprinkler System - Out of Service K 354 6/10/17 Event : KNFH21 Facility : H061002 If continuation sheet Page 5 of 23
SUMMARY PROVER'S PLAN OF CORRECTION K 354 Continued From page 5 K 354 Sprinkler System - Out of Service Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service. 18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25) This STANDARD is not met as evidenced by: Based on observation, record review and interview the facility does not assure a fire watch procedure and policy is written as required for implementation when the fire sprinkler system is out of service for more than 10 hours in a 24 hour period. This deficient practice would prevent proper notification of insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction as required, affecting all residents/patients in all smoke zones. The facility has a capacity of 60 with a census of 45 at the time of survey. Findings include: During the survey on May 9th, 2017 the following is observed at 10:00 a.m. during records review: 1. It is revealed that the facility's written policy for implementing a fire watch for sprinkler system impairment does not include notification of the Event : KNFH21 Facility : H061002 If continuation sheet Page 6 of 23
SUMMARY PROVER'S PLAN OF CORRECTION K 354 Continued From page 6 K 354 insurance carrier, the alarm company, property owner or designated representative. The Chief Operating Officer, maintenance director and safety/security chief were present during the survey and acknowledged the findings. Sprinkler System Impairments. Sprinkler impairment procedures shall comply with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2012 NFPA 101, 9.7.6 All preplanned impairments shall be authorized by the impairment coordinator. 2011 NFPA 25, 15.5.1 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented: (1) The extent and expected duration of the impairment have been determined. (2) The areas or buildings involved have been inspected and the increased risks determined. (3) Recommendations have been submitted to management or the property owner or designated representative. (4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following: (a) Evacuation of the building or portion of the building affected by the system out of service (b) An approved fire watch Event : KNFH21 Facility : H061002 If continuation sheet Page 7 of 23
SUMMARY PROVER'S PLAN OF CORRECTION K 354 Continued From page 7 K 354 (c) Establishment of a temporary water supply (d) Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire (5) The fire department has been notified. (6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified. (7) The supervisors in the areas to be affected have been notified. (8) A tag impairment system has been implemented. (See Section 15.3.) (9) All necessary tools and materials have been assembled on the impairment site. 2011 NFPA 25, 15.5.2 Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure. When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage. The coordinator shall implement the steps outlined in Section 15.5. 2011 NFPA 25, 15.6.1, 15.6.2 & 15.6.3 Restoring Systems to Service. When all impaired equipment is restored to normal working order, the impairment coordinator shall verify that the following procedures have been implemented: (1) Any necessary inspections and tests have been conducted to verify that affected systems are operational. The appropriate chapter of this standard shall be consulted for guidance on the type of inspection and test required. Event : KNFH21 Facility : H061002 If continuation sheet Page 8 of 23
SUMMARY PROVER'S PLAN OF CORRECTION K 354 Continued From page 8 K 354 K 363 (2) Supervisors have been advised that protection is restored. (3) The fire department has been advised that protection is restored. (4) The property owner or designated representative, insurance carrier, alarm company, and other authorities having jurisdiction have been advised that protection is restored. (5) The impairment tag has been removed 2011 NFPA 25, 15.7 NFPA 101 Corridor - Doors Corridor - Doors 2012 EXISTING Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed. There is no impediment to the closing of the doors. Clearance between bottom of door and floor covering is not exceeding 1 inch. Roller latches are prohibited by CMS regulations on corridor doors and rooms containing flammable or combustible materials. Powered doors complying with 7.2.1.9 are permissible. 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 K 363 6/10/17 Event : KNFH21 Facility : H061002 If continuation sheet Page 9 of 23
SUMMARY PROVER'S PLAN OF CORRECTION K 363 Continued From page 9 K 363 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: Based on observation and staff interview the facility is not ensuring that room doors latch properly and are free of impediments that prevent the doors from being closed. This deficient practice of not ensuring that room doors latch properly and are free of impediments prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting all residents in one of two smoke zones. The facility has a capacity of 60 with a census of 45 at the time of survey. Findings include: During the survey on May 9th, 2017 the following is observed: 1. At 2:10 p.m. on the A2 side of the building there is a folded piece of paper obstructing the door strike plate of room 128; this is keeping the door from latching. This door opens into the corridor. The Chief Operating Officer, maintenance director and safety/security chief were present during the survey and acknowledged the findings. Doors shall be provided with a means for keeping the door closed that is acceptable to the authority Event : KNFH21 Facility : H061002 If continuation sheet Page 10 of 23
SUMMARY PROVER'S PLAN OF CORRECTION K 363 Continued From page 10 K 363 having jurisdiction and the following requirements also shall apply: (1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. (2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7. 2012 NFPA 101, 19.3.6.3.5 Doors shall not be held open by devices other than those that release when the door is pushed or pulled. 2012 NFPA 101, 19.3.6.3.10 K 372 NFPA 101 Subdivision of Building Spaces - Smoke Barrie K 372 6/10/17 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: Based on observation and staff interview the facility fails to maintain one of one smoke barrier to at least one half hour fire resistance. This deficient practice would prevent containment of Event : KNFH21 Facility : H061002 If continuation sheet Page 11 of 23
SUMMARY PROVER'S PLAN OF CORRECTION K 372 Continued From page 11 K 372 fire and smoke, affecting all residents in two of two smoke zones. The facility has a capacity of 60 and census of 45 at the time of the survey. Findings include: During the survey on May 9th, 2017 the following is observed: 1. At 2:40 p.m. there is an approximate 2 inch hole in the smoke barrier around electrical conduit. This hole has had a rag stuffed in it. This is located above the ceiling over the smoke barrier door on the building 2 side. 2. At 2:45 p.m. there is a ½ inch to 1 inch unsealed gap along the top of the drywall where the smoke barrier meets the roof deck. This is inside room 122 above the ceiling on the building 1 side. This gap extends the entire length of the room. The Chief Operating Officer, maintenance director and safety/security chief were present during the survey and acknowledged the findings. Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum ½ hour fire resistance rating, unless otherwise permitted by one of the following: (1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply: (a) Smoke barriers shall be permitted to terminate Event : KNFH21 Facility : H061002 If continuation sheet Page 12 of 23
SUMMARY PROVER'S PLAN OF CORRECTION K 372 Continued From page 12 K 372 at an atrium wall constructed in accordance with 8.6.7 (1) (c). (b) Not less than two separate smoke compartments shall be provided on each floor. (2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier. 2012 NFPA 101, 19.3.7.3 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier, or by use of a combination thereof. Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces. 2012 NFPA 101, 8.5.2.1 and 8.5.2.2 The provisions of 8.5.6 shall govern the materials and methods of construction used to protect through-penetrations and membrane penetrations of smoke barriers. Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke. Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread Event : KNFH21 Facility : H061002 If continuation sheet Page 13 of 23
SUMMARY PROVER'S PLAN OF CORRECTION K 372 Continued From page 13 K 372 K 711 of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met. Where sprinklers penetrate a single membrane of a fire resistance-rated assembly in buildings equipped throughout with an approved automatic fire sprinkler system, noncombustible escutcheon plates shall be permitted, provided that the space around each sprinkler penetration does not exceed 112 in. (13 mm), measured between the edge of the membrane and the sprinkler. Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be securely set in the smoke barrier, and the space between the item and the sleeve shall be filled with a material capable of restricting the transfer of smoke. 2012 NFPA 101, 8.5.6.1 through 8.5.6.5 NFPA 101 Evacuation and Relocation Plan Evacuation and Relocation Plan There is a written plan for the protection of all patients and for their evacuation in the event of an emergency. Employees are periodically instructed and kept informed with their duties under the plan, and a copy of the plan is readily available with telephone operator or with security. The plan addresses the basic response required of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan components per 18/19.2.2. 18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3 This STANDARD is not met as evidenced by: Based on record review and staff interview the facility failed to carry out the provisions of the written fire safety plan during drill activities. The K 711 6/10/17 Event : KNFH21 Facility : H061002 If continuation sheet Page 14 of 23
SUMMARY PROVER'S PLAN OF CORRECTION K 711 Continued From page 14 K 711 deficient practice may prevent the staff from identifying the proper procedures to take during an actual emergency, affecting all residents in six of six smoke zones. The facility has a capacity of 60 and census of 45 at the time of the survey. Findings include: During the survey on May 9th, 2017 the following is observed at 10:30 a.m. during records review and staff interviews: 1. The facility's fire response plans indicates staff should evacuate the immediate area of the fire. The plan does not describe what the immediate area is, or who to evacuate first. The Chief Operating Officer, maintenance director and safety/security chief were present during the survey and acknowledged the findings.. NFPA Standard: 2012 NFPA 101, 19.1.1.3.2 Because the safety of health care occupants cannot be ensured adequately by dependence on evacuation of the building, their protection from fire shall be provided by appropriate arrangement of facilities; adequate, trained staff; and development of operating and maintenance procedures composed of the following: (1) Design, construction, and compartmentation (2) Provision for detection, alarm, and extinguishment (3) Fire prevention procedures and planning, training, and drilling programs for the isolation of fire, transfer of occupants to areas of refuge, or evacuation of the building NFPA Standard: 2012 NFPA 101, 19.7.2.2 Fire Event : KNFH21 Facility : H061002 If continuation sheet Page 15 of 23
SUMMARY PROVER'S PLAN OF CORRECTION K 711 Continued From page 15 K 711 K 712 Safety Plan. A written health care occupancy fire safety plan shall provide for all of the following: (1) Use of alarms (2) Transmission of alarms to fire department (3) Emergency phone call to fire department (4) Response to alarms (5) Isolation of fire (6) Evacuation of immediate area (7) Evacuation of smoke compartment (8) Preparation of floors and building for evacuation (9) Extinguishment of fire NFPA 101 Fire Drills Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at 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. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7 This STANDARD is not met as evidenced by: Based on record review and staff interview, the facility is not conducting fire drills as required and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all residents in all smoke zones. The facility has a capacity of 60 with a census of 45 at the time of survey. K 712 6/10/17 Event : KNFH21 Facility : H061002 If continuation sheet Page 16 of 23
SUMMARY PROVER'S PLAN OF CORRECTION K 712 Continued From page 16 K 712 Findings include: During the survey on May 9th, 2017 the following is observed at 11:10 a.m. during records review: 1. Review of fire drill records for the last 6 quarters revealed that all of the drills conducted on the night shift were silent drills. Upon staff interviews it is revealed that the fire alarm is not being tested on the following day. 2. Review of fire drill records for the last 6 quarters revealed that the evening shift did not participate in a fire drill during the 4th quarter of 2016. 3. Review of fire drill records for the last 6 quarters revealed that the drills conducted on 4/25/17, 4/19/17, 2/17/17, 1/18/17, 1/24/17, 1/18/17, 11/20/16, 6/21/16, 5/23/16, 4/13/16, 3/22/16, and 2/18/16 did not include any type of scenario. 4. Every fire drill performed on the evening shift for the last 6 quarters took place during the 4:00 p.m. hour. 5. Every fire drill performed on the night shift for the last 6 quarters took place between 4:45 a.m. and 5:55 a.m. The Chief Operating Officer, maintenance director and safety/security chief were present during the survey and acknowledged the findings. Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 2012 NFPA 101, 19.7.1.4 Event : KNFH21 Facility : H061002 If continuation sheet Page 17 of 23
SUMMARY PROVER'S PLAN OF CORRECTION K 712 Continued From page 17 K 712 K 918 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. 2012 NFPA 101, 19.7.1.6 NFPA 101 Electrical Systems - Essential Electric Syste 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 and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design K 918 6/10/17 Event : KNFH21 Facility : H061002 If continuation sheet Page 18 of 23
SUMMARY PROVER'S PLAN OF CORRECTION K 918 Continued From page 18 K 918 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: Based on record review and staff interview the facility failed to assure the generator is inspected and tested in accordance with NFPA 110 Standard for Emergency and Standby Power Systems. This deficient practice fails to ensure that the generator will not fail when needed in the event of an emergency, affecting all residents in all smoke zones. The facility has a capacity of 60 and census of 45 at the time of the survey. Findings include: During the survey on May 9th, 2017 the following is observed at 9:15 a.m. during records review: 1. While reviewing documentation from the last 6 quarters it is revealed that no weekly inspections have been performed on the generator 2. The form being used to document generator maintenance references the 1999 edition of NFPA 110. 3. For the monthly generator tests performed on 2-14-16 and 6-14-16 there is not a transfer time listed, and the transfer time on the tests performed on 8-9-16, 11-15-16, and 12-13-16 exceeded the allowed transfer time the longest time being 39 seconds. The Chief Operating Officer, maintenance director and safety/security chief were present during the survey and acknowledged the findings. Event : KNFH21 Facility : H061002 If continuation sheet Page 19 of 23
SUMMARY PROVER'S PLAN OF CORRECTION K 918 Continued From page 19 K 918 Where required for compliance with this Code, emergency generators and standby power systems shall comply with 9.1.3.1 and 9.1.3.2. 2012 NFPA 101, 9.1.3 Emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. 2012 NFPA 101, 9.1.3.1 EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. 2010 NFPA 110, 8.4.1 A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available. The permanent record shall include the following: (1) The date of the maintenance report (2) Identification of the servicing personnel (3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced (4) Testing of any repair for the time as recommended by the manufacturer. 2010 NFPA 110, 8.3.4, 8.3.4.1 EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. 2010 NFPA 110, 8.4.1 All installations shall have a remote manual stop Event : KNFH21 Facility : H061002 If continuation sheet Page 20 of 23
SUMMARY PROVER'S PLAN OF CORRECTION K 918 Continued From page 20 K 918 K 920 station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. The remote manual stop station shall be labeled. 2010 NFPA 110, 5.6.5.6, 5.6.5.6.1 NFPA 101 Electrical Equipment - Power Cords and Extens 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: Based on observation and staff interview, the facility fails to assure that all electrical wiring and equipment is installed and maintained in K 920 6/10/17 Event : KNFH21 Facility : H061002 If continuation sheet Page 21 of 23
SUMMARY PROVER'S PLAN OF CORRECTION K 920 Continued From page 21 K 920 accordance with the requirements NFPA 70 National Electrical Code. This deficient practice increases the risk of an electrical fire. The deficient practice would affect approximately 15 employees in two of two smoke zones. The facility has a capacity of 60 and census of 45 at the time of the survey. Findings include: During the survey on May 9th, 2017 the following is observed: : 1. At 2:05 p.m. there is a power strip plugged into a power strip in room 131 of building 2. 2. At 2:10 p.m. there is an overloaded power strip with a refrigerator and a microwave both plugged into it in room 129 of building 2. 3. At 2:20 p.m. this is an overloaded power strip with a refrigerator and a microwave both plugged into in in room 129 of building 1. The Chief Operating Officer, maintenance director and safety/security chief were present during the survey and acknowledged the findings. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2012 NFPA 101, 9.1.2 Where used as permitted in 400.7(A)(3), (A)(6), and (A)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet or cord connector body. Event : KNFH21 Facility : H061002 If continuation sheet Page 22 of 23
SUMMARY PROVER'S PLAN OF CORRECTION K 920 Continued From page 22 K 920 Exception: As permitted in 368.56. 2011 NFPA 70, 400.7 Unless specifically permitted, flexible cords and cable shall not be used as a substitute for fixed wiring of a structure. 2011 NFPA 70, 400-8 In no case shall the load exceed the branch-circuit ampere rating. An individual branch circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or receptacles shall supply only the loads specified according to its size as specified in 210.23(A) through (D) and as summarized in 210.24 and Table 210.24. 2011 NFPA 70, 210.23 Event : KNFH21 Facility : H061002 If continuation sheet Page 23 of 23