e 0000 · 2018-11-20 · following the date of survey whether or not a plan of correction is...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

11/19/2018PRINTED:

FORM APPROVED

OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE

(X4) ID

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SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

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IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

(X5)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

INDIANAPOLIS, IN 46280

15C0001086 08/10/2018

BELTWAY SURGERY CENTERS LLC

151 PENNSYLVANIA PKWY

--

E 0000

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An Emergency Preparedness Survey was

conducted by the Indiana State Department of

Health in accordance with 42 CFR 416.54

Survey Date(s): 08/09/18 & 08/10/18

Facility Number: 002277

Provider Number: 15C0001086

AIM Number: 200255810A

At this Emergency Preparedness survey, Beltway

Surgery Centers LLC was found not in

compliance with Emergency Preparedness

Requirements for Medicare and Medicaid

Participating Providers and Suppliers, 42 CFR

416.54

Quality Review completed on 08/16/18 - DA

The requirement at 42 CFR, Subpart 416.54 is

NOT MET as evidenced by:

E 0000

E 0026

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Based on record review and interview, the facility

failed to ensure emergency preparedness policies

and procedures include the role of the ASC

facility under a waiver declared by the Secretary,

in accordance with section 1135 of the Act, in the

provision of care and treatment at an alternate

care site identified by emergency management

officials in accordance with 42 CFR 416.54(b)(6).

This deficient practice could affect all occupants.

Findings include:

Based on review of "Emergency Response Plan"

E 0026 Correction of deficit: A new

policy was created to address the

documentation specific to the role

of the ASC facility under a waiver

declared by the Secretary, in

accordance with section 1135 of

the ACT.

Prevention of recurring

deficiency: Staff will be educated

on the new policy with the annual

review. Policy attached.

Responsible: The clinical director

is responsible for correction of

08/29/2018 12:00:00AM

FORM CMS-2567(02-99) Previous Versions Obsolete

Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determined that

other safegaurds 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.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

_____________________________________________________________________________________________________Event ID: EOYR21 Facility ID: 002277

TITLE

If continuation sheet of 39

(X6) DATE




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and "MultiSpecialty Surgery Center Policies and

Procedures Manual" documentation with the

Director of ASC Clinical Operations, the

Manager of OR Clinical Operations, the Manager

of PACU Clinical Operations and the Building

Engineer for Health Care Trust of America

(HTA) during record review from 10:15 a.m. to

4:20 p.m. on 08/09/18, the emergency

preparedness plan for the facility did not

expressly state the role of the facility under a

waiver declared by the Secretary, in accordance

with section 1135 of the Act. Based on interview

at the time of record review, the Director of ASC

Clinical Operations stated they must follow IU

Health & Safety notification procedures in the

event of an emergency which may include the role

of the facility under a waiver declared by the

Secretary but agreed documentation for the role

of the facility under a waiver in accordance with

section 1135 of the Act was not available for

review at the time of the survey.

this deficiency.

E 0031

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failed to ensure the emergency preparedness

communication plan includes (2) Contact

information for the following: (i) Federal, State,

tribal, regional, or local emergency preparedness

staff (ii) Other sources of assistance in accordance

with 42 CFR 416.54(c)(2). This deficient

practice could affect all occupants.

Findings include:

Based on review of "Emergency Response Plan"

and "MultiSpecialty Surgery Center Policies and

Procedures Manual" documentation with the



E 0031 Correction of deficit: The

emergency response plan was

updated to include Contact

information for ISDH via the ISDH

Gateway link at

https://gateway.isdh.in.gov as the

primary contact and secondary

method when the ISDH Gateway

is nonoperational, using the

reporting form. This was

also included in the center's

emergency contact information.



on the updated plan with the

annual review.

08/27/2018 12:00:00AM

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EOYR21 Facility ID: 002277 If continuation sheet of 39

https://gateway.isdh.in.gov/












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4:20 p.m. on 08/09/18, the emergency

preparedness plan did not include contacting the

Indiana State Department of Health via the ISDH

Gateway link at https://gateway.isdh.in.gov as the

primary method or by the secondary method when

the ISDH Gateway is nonoperational by

completing the Incident Reporting form and

e-mailing it to [email protected]. Based on

interview at the time of record review, the

Director of ASC Clinical Operations agreed the

emergency preparedness program documentation

did not include contacting ISDH via the

aforementioned methods.



this deficiency.

K 0000

Bldg. 01

A Life Safety Code Recertification Survey was

conducted by the Indiana State Department of

Health in accordance with 42 CFR 416.44(b).

Survey Date(s): 08/09/18 & 08/10/18

Facility Number: 002277

Provider Number: 15C0001086

AIM Number: 200255810A

At this Life Safety Code survey, Beltway Surgery

Centers Llc was found not in compliance with

Requirements for Participation in

Medicare/Medicaid, 42 CFR Subpart 416.44(b),

Life Safety from Fire and the 2012 edition of the

National Fire Protection Association (NFPA) 101,

Life Safety Code (LSC).

The facility, located on the second and third story

of a three story building with a basement, was

determined to be of Type II (000) construction

K 0000





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and was fully sprinklered except for the basement

elevator machine room and the adjoining

basement hallway. The facility was surveyed with

NFPA 101, LSC Chapter 21, Existing

Ambulatory Health Care Occupancies. The

facility has a fire alarm system with smoke

detection at the first floor reception area, in the

corridor outside the elevators, in the corridor

outside the Operating Rooms and at the main fire

panel on the second floor.

Quality Review completed on 08/16/18 - DA

NFPA 101

Multiple Occupancies

Multiple Occupancies - Sections of

Ambulatory Health Care Facilities

Multiple occupancies shall be in accordance

with 6.1.14.

Sections of ambulatory health care facilities

shall be permitted to be classified as other

occupancies, provided they meet both of the

following:

* The occupancy is not intended to serve

ambulatory health care occupants for

treatment or customary access.

* They are separated from the ambulatory

health care occupancy by a 1 hour fire

resistance rating.

Ambulatory health care facilities shall be

separated from other tenants and

occupancies and shall meet all of the

following:

* Walls have not less than 1 hour fire

resistance rating and extend from floor slab

to roof slab.

* Doors are constructed of not less than

1-3/4 inches thick, solid-bonded wood core

or equivalent and is equipped with positive

latches.

* Doors are self-closing and are kept in the

closed position, except when in use.

K 0131

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* Windows in the barriers are of fixed fire

window assemblies per 8.3.

Per regulation, ASCs are classified as

Ambulatory Health Care Occupancies,

regardless of the number of patients served.

20.1.3.2, 21.1.3.3, 20.3.7.1, 21.3.7.1,42 CFR

416.44

Based on record review, observation and

interview; the facility failed to ensure 1 of 1 fire

barriers that separate other occupancies were

protected to maintain the fire resistance rating of

the fire barrier. NFPA 101, 2012 edition, Section

8.3.5.6.1 states membrane penetrations for cables

cable trays conduits, pipes, tubes, combustion

vents and exhaust vents, wires, and similar items

to accommodate electrical, mechanical, plumbing,

and communications systems that pass through a

membrane of a wall, floor, or floor/ceiling

assembly constructed as a fire barrier shall be

protected by a firestop system or device. Section

8.3.5.6.2 states the firestop system or device shall

be tested in accordance with ASTM E 814,

Standard Test Method for Fire Test of Through

Penetration Fire stops, or ANSI/UL 1479,

Standard for Fire Tests of Through-Penetration

Firestops. In addition, doors are self-closing and

are kept in the closed position, except when in

use. This deficient practice could affect all

patients, staff and visitors.

Findings include:

Based on observations with the Director of ASC

Clinical Operations, the Manager of OR Clinical

Operations, the Manager of PACU Clinical

Operations and with the Building Engineer for

Health Trust of America (HTA) during a tour of

the facility from 10:00 a.m. to 2:10 p.m. on

08/10/18, the following was noted in the tenant

separation fire barrier wall located on the east

side of the atrium:

K 0131 Correction of deficit: The

center's facility manager has

contracted with an outside

vendor to correct the

deficiencies. A quote was

recieved for the project on

8/30/2018.


deficiency: The facility manager

will inspect all ceiling work to

ensure that any firewall

penetration is corrected properly.

Responsible: The facility

manager is responsible for

correction of this deficiency.

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a. a two inch by two inch hole for the passage of

one data cable was noted in the wall above the

suspended ceiling above the corridor door set

serving as the entrance to the Medical Office

Building on the third floor. The wall consisted of

four layers of 5/8ths inch thick drywall.

b. a two inch by two inch hole for the passage of

two electrical conduits was noted in the wall

above the suspended ceiling above the corridor

door set serving as the entrance to the Medical

Office Building on the second floor. The wall

consisted of four layers of 5/8ths inch thick

drywall.

Based on interview at the time of the

observations, the Building Engineer for HTA

agreed the aforementioned holes did not maintain

the minimum fire resistance rating for the east

tenant separation fire wall.

NFPA 101

Building Construction Type and Height

Building Construction Type and Height

Building construction type and stories meet

Table 20.1.6.1 or Table 21.1.6.1,

respectively.

Construction Type

1 I (442), I (332), II (222), Any

number of stories

II (111), III (211), IV (2HH),

non-sprinklered or sprinklered

V (111)

2 II (000), III (200), V (000) One

story non-sprinklered

Any number of stories

sprinklered

Any level below the level of exit discharge

shall be separated by Type II (111), Type III

(211), or Type V (111) construction unless

K 0161

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both of the following are met:

1. Such levels are under the control of the

ambulatory health care occupancy.

2. Hazardous spaces are protected per

section 8.7.

Sprinklered stories must be sprinklered

throughout by an approved, supervised

automatic system in accordance with section

9.7. (See 20.3.5 or 21.3.5, respectively)

Give a brief description, in REMARKS, of the

construction, the number of stories,

including basements, floors on which

patients are located, location of smoke or

fire barriers and dates of approval. Complete

sketch or attach small floor plan of the

building as appropriate.

20.1.6.1, 20.1.6.2, 21.1.6.1, 21.1.6.2


interview; the facility failed to ensure the building

construction type was a permitted type as listed in

Table 21.1.6.1. Table 21.1.6.1 requires a

building of Type II(000) construction and two or

more stories in height to be fully sprinklered.

This deficient practice could affect all patients

and visitors.

Findings include:

Based on record review with the Director of ASC



Operations and the Building Engineer for Health

Care Trust of America (HTA) from 10:15 a.m. to

4:20 p.m. on 08/09/18, facility blueprint

documentation and facility construction type

documentation was not available for review.





HTA during a tour of the facility from 10:00 a.m.



issued a purchase order to

complete fire proofing and to

ensure the basement elevator

machine room and adjoining

room are sprinklered. Required

parts were ordered the week of

9/3 for the sprinkler additions.

The sprinkler vendor has stated

that lead time on waterproof

controls and panel is 6-8 weeks.



will ensure the facility meets

current code requirements

through rounding and routine

maintenance of the facility.




10/27/2018 12:00:00AM





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to 2:10 p.m. on 08/10/18, unprotected steel was

noted for the load bearing columns and the

support beams for floor decking in the supply

room for the second floor Bistro. The Bistro is

located in the three story atrium and is open to the

atrium. The atrium was not separated from the

surgery center suite with two hour fire resistive

construction. Protected steel was noted in load

bearing walls and columns throughout the surgery

suite with a minimum construction type of Type

II(111). In addition, the basement elevator

machine room and the hallway outside the

machine room in the basement were not

sprinklered. Based on interview at the time of the

observations, the Director of ASC Clinical

Operations stated the second and third floor

atrium serves as the patient waiting area for the

surgery center. Based on interview at the time of

the observations, the Building Engineer for HTA

agreed unprotected steel was noted in the load

bearing columns and the support beams for floor

decking in the supply room for the Bistro and

stated the basement elevator machine room and

hallway outside the machine room were not

sprinklered.

NFPA 101

Doors with Self-Closing Devices

Doors with Self-Closing Devices

Doors required to be self-closing are

permitted to be held open by a release

device complying with 7.2.1.8.2 that

automatically closes all such doors

throughout the smoke compartment, entire

facility, and all stair enclosure doors upon

activation of:

* Required manual fire alarm system, and

* Local smoke detectors designed to detect

smoke passing through the opening or a

required smoke detection system; and

* Automatic sprinkler system, if installed;

K 0223

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and

* Loss of power

20.2.2.4, 20.2.2.5, 21.2.2.4, 21.2.2.5

Based on observation and interview, the facility

failed to ensure 3 of over 10 self closing doors

would self close to form a smoke resistant barrier.

This deficient practice could affect seven patients

and staff.

Findings include:







08/10/18, the corridor door to the vestibule by the

elevator within the surgery suite on the second

and third floor was held open with a magnetic

holding device set to release with the fire alarm

system. Each of the two doors failed to self close

and latch into the door frame when tested to close

multiple times. In addition, the third floor

stairwell door by Operating Room 9 was

equipped with a self closing device but the door

failed to fully close and latch into the door frame

when tested to close multiple times. Based on

interview at the time of the observations, the

Building Engineer for HTA agreed the

aforementioned self closing doors failed to self

close and latch into the door frame.


center's facility

manager has contracted with an

outside vendor to complete the

repairs to the doors outlined in

the statement of

deficiencies. The doors require

specialized parts that have a 2 to

3 week lead time.










09/28/2018 12:00:00AM

NFPA 101

Emergency Lighting

Emergency Lighting

Emergency lighting of at least 1-1/2 hour

duration is provided automatically in

accordance with 7.9.

20.2.9.1, 21.2.9.1, 7.9

K 0291

Bldg. 01

Based on observation and interview, the facility K 0291 Correction of deficit: The 09/07/2018 12:00:00AM





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failed to ensure 3 of over 10 battery powered

emergency lights were maintained in accordance

with LSC 7.9. LSC 7.9.2.6 states battery operated

emergency lights shall use only reliable types of

rechargeable batteries provided with suitable

facilities for maintaining them in properly charged

condition. Batteries used in such lights or units

shall be approved for their intended use and shall

comply with NFPA 70 National Electric Code.

LSC 7.9.2.7 states the emergency lighting system

shall be either continuously in operation or shall

be capable of repeated automatic operation

without manual intervention. This deficient

practice could affect all patients, staff and

visitors.

Findings include:







08/10/18, each of the two battery operated

emergency lights located in the outdoor enclosure

for the facility's emergency generator location

failed to function when its respective test button

was pushed multiple times. In addition, the

battery operated emergency light located in the

SIMS basement supply room also failed to

function when its respective test button was

pushed multiple times. Based on interview at the

time of the observations, the Building Engineer

for HTA stated rain water can get in the battery

operated lights at the generator causing them to

fail to function and agreed each of the

aforementioned three battery operated emergency

lights failed to function when its respective test

button was pushed multiple times.

center's facility



repairs to the three emergency

lights.














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NFPA 101

Protection - Other

Protection - Other

List in the REMARKS section any LSC

Section 20.3 and 21.3 Protection

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.

K 0300

Bldg. 01


failed to ensure 2 of over 10 doors equipped with

latching devices latched into its respective door

frame. NFPA 101 in 4.6.12.3 states existing life

safety features obvious to the public, if not

required by the Code, shall be maintained. This

deficient practice could affect all patients, staff,

and visitors.

Findings include:







08/10/18, the following was noted in the required

smoke barrier wall for compartmentation of each

floor:

a. the latching hardware in the west door in the

corridor door set serving as the main entrance to

the operating room corridor on the third floor

failed to function correctly and latch the door into

the door frame. The cover for the latching

hardware at the top of the door was removed and

a binder clip was inserted in the latching

hardware.

b. the strike plate was missing on the door frame

for the west door in the corridor door set serving

as the main entrance to the operating room


center's facility



repairs to the doors outlined in

the statement of

deficiencies. The doors require

specialized parts that have a 4

to 5 week lead time










10/05/2018 12:00:00AM





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corridor on the second floor. With the strike

place missing, the latching hardware failed to

function properly to latch the door into the door

frame.



agreed the aforementioned latching devices failed

to function properly to latch the door into the

door frame.

NFPA 101

Vertical Openings - Enclosure

Vertical Openings - Enclosure

2012 EXISTING

Vertical openings shall be enclosed or

protected per 8.6, unless one of the

following conditions exist:

1. Unenclosed vertical openings per

8.6.9.1 are permitted.

2. Unenclosed openings which do not

serve as a required means of egress are

permitted.

3. Exit access stairs may be unenclosed if

they meet the following conditions:

Two stories or less

a. Building is protected throughout by a

supervised sprinkler system per 9.7.1.1(1).

b. Total travel distance to outside does

not exceed 100 feet.

Three stories or less

a. Occupant load per story does not

exceed 15 people.

b. Building is sprinkler protected

throughout per 9.7.1.1(1).

c. Building contains an automatic

smoke detection system per 9.6.

d. Activation of the sprinkler system or

smoke detection system notifies all

occupants of the building.

e. Total travel distance to outside does

not exceed 100 feet.

Floors that are below the street level and are

K 0311

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used for storage or any use other than a

business occupancy, shall not have any

unprotected openings to the business

occupancy floors.

21.3.1, 39.3.1.1, 39.3.1.2


failed to maintain protection of 1 of 2 interior

stairwells. LSC 21.3.1 requires protection of

vertical openings in accordance with 39.3.1. LSC

39.3.1 requires vertical opening shall be enclosed

or protected in accordance with Section 8.6. LSC

8.6.1 requires every floor that separates stories in

a building shall be constructed as a smoke barrier.

LSC 8.6.5 states see 7.1.3.2.1 for enclosures of

exits. LSC 7.1.3.2.1 states the separation shall

have a minimum 1-hr fire resistance rating where

the exit connects three stories or less. Openings

in the separation shall be protected by fire door

assemblies equipped with door closers complying

with 7.2.1.8. Existing penetrations shall be

protected in accordance with 8.3.5. This deficient


visitors.

Findings include:







08/10/18, the third floor stairwell door by

Operating Room 9 was equipped with a self

closing device but the door failed to fully close

and latch into the door frame when tested to close

multiple times. The door was rated at 90 minute

fire resistance rating with an affixed rating label.



agreed the aforementioned stairwell door failed to


center's facility

manager has corrected the door

latching mechanism.










08/24/2018 12:00:00AM





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fully close and latch into the door frame when

tested to close multiple times.

NFPA 101

Fire Alarm System - Testing and

Maintenance

Fire Alarm Systems - 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

K 0345

Bldg. 01

1. Based on record review and interview, it could

not be assured all facility fire alarm system

initiating devices were functional tested annually.

LSC 9.6.1.3 requires a fire alarm system to be

installed, tested, and maintained in accordance

with NFPA 70, National Electrical Code and

NFPA 72, National Fire Alarm and Signaling

Code. NFPA 72, 2010 Edition, Section 14.4.5

states unless otherwise permitted by other sections

of this code, testing shall be performed in

accordance with the schedules in Table 14.4.5, or

more often if required by the authority having

jurisdiction. Table 14.4.5 Testing Frequencies

states initiating devices shall be functional tested

annually. This deficient practice could affect all

patients, staff and visitors.

Findings include:

Based on review of Koorsen Fire & Security

"Inspection and Test Report" documentation

dated 01/27/18 with the Director of ASC Clinical

Operations, the Manager of OR Clinical



center's facility manager will

ensure the following corrective

steps:

A. Contracted with an outside

vendor to provide functional

testing for all smoke

detectors and all duct detectors.

Results of that testing will be

maintained by the facility

manager.

b. The main fire panel room

behind the second floor Bistro

supply room will be restricted to

authorized personnel. The entry

door to the room, the electrical

panel containing the breaker and

the breaker will be locked at all

times.

c. Contracted with an outside

vendor to verify and correct, if

needed, that the fire alarm

system breaker is on the

emergency generator.


09/29/2018 12:00:00AM





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Care Trust of America (HTA) during record

review from 10:15 a.m. to 4:20 p.m. on 08/09/18,

the results of functional testing for 14 of 31

smoke detectors were documented as "Visual" or

"Not Tested." Functional testing results for 4 of

28 duct detectors were also listed as "Visual" or

"Not Tested" and functional testing results for 2

of 19 manual pull stations were listed as "Visual."

Based on interview at the time of record review,

the Building Engineer for HTA stated additional

functional testing documentation for all fire alarm

system initiating devices not functional tested on

01/27/18 within the most recent twelve month

period was not available for review at the time of

the survey.

2. Based on observation and interview, the

facility failed to ensure 1 of 1 fire alarm systems

was maintained in accordance with the applicable

requirements of NFPA 72, National Fire Alarm

Code. NFPA 72, 2010 Edition, Section 10.5.5.1

states connections to the light and power service

shall be on a dedicated branch circuit(s). Circuit

disconnecting means shall have a red marking,

shall be accessible only to authorized personnel,

and shall be identified as FIRE ALARM

CIRCUIT. The location of the circuit

disconnecting means shall be permanently

identified at the fire alarm control unit. Section

10.5.5.4 states an overcurrent protective device of

suitable current carrying capacity and capable of

interrupting the maximum short circuit current to

which it may be subject shall be provided in each

ungrounded conductor. The dedicated branch

circuit(s) and connections shall be protected

against physical damage. This deficient practice

could affect all patients, staff and visitors.

Findings include:













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08/10/18, access to the fire alarm system breaker

located in the electrical panel identified as

"LRPZ" in the main fire panel room behind the

second floor Bistro supply room was not

restricted to authorized personnel. The entry door

to the room, the electrical panel containing the

breaker and the breaker were each not locked. In

addition, it could not be assured the fire alarm

system breaker was also on the emergency

generator should the primary power source be on

emergency generator power. Based on interview

at the time of the observations, the Building

Engineer for HTA stated the electrical panel

containing the breaker was not also on the

emergency generator and agreed access to the fire

alarm system breaker was not restricted to

authorized personnel.

NFPA 101

Fire Alarm System - Out of Service

Fire Alarm - Out of Service

Fire alarms that are out of service for 4

hours in a 24 hour period, the authority

having jurisdiction shall be notified, and the

building shall be evacuated or an approved

fire watch shall be provided for all parties left

unprotected by the shutdown until the fire

alarm system has been returned to service.

9.6.1.6

K 0346

Bldg. 01


failed to provide a complete written policy for the

protection of patients indicating procedures to be

followed in the event the fire alarm system has to

be placed out of service for four hours or more in

a twenty four hour period in accordance with





Gateway link at


08/27/2018 12:00:00AM














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LSC, Section 9.6.1.6. This deficient practice

could affect all patients, staff, and visitors.

Findings include:

Based on review of "Emergency Response Plan:

Fire Watch - Incident Action Plan"

documentation with the Director of ASC Clinical






the fire watch plan for fire alarm system

impairment was incomplete. The plan failed to

include contacting the Indiana State Department

of Health via the ISDH Gateway link at

https://gateway.isdh.in.gov as the primary method

or by the secondary method when the ISDH

Gateway is nonoperational by completing the

Incident Reporting form and e-mailing it to

[email protected]. Based on interview at the

time of record review, the Director of ASC

Clinical Operations agreed the fire watch

documentation for fire alarm system impairment

did not state to contact the Indiana State

Department of Health via the ISDH Gateway link

or at the e-mail address listed above.










annual review.



this deficiency.

Plan attached.

NFPA 101

Sprinkler System - Installation

Sprinkler System - Installation

Sprinkler systems (if installed) are installed

per NFPA 13.

Where more than two sprinklers are

installed in a single area for protection,

waterflow devices shall be provided to sound

the building fire alarm system or to notify a

constantly attended location such as a PBX,

security office, or emergency room.

20.3.5.1, 20.3.5.2, 21.3.5.1, 21.3.5.2,

K 0351

Bldg. 01





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9.7.1.2, 9.7, NFPA 13


facility failed to ensure the spray pattern for

sprinkler heads were not obstructed in 3 of over

50 rooms in accordance with NFPA 13, Standard

for the Installation of Sprinkler Systems. NFPA

13, 2010 edition, Section 8.5.5.1 states sprinklers

shall be located so as to minimize obstructions to

discharge as defined in 8.5.5.2 and 8.5.5.3 or

additional sprinklers shall be provided to ensure

adequate coverage of the hazard. Sections 8.5.5.2

and 8.5.5.3 do not permit continuous or

noncontinuous obstructions less than or equal to

18 inches below the sprinkler deflector or in a

horizontal plane more than 18 inches below the

sprinkler deflector that prevent the spray pattern

from fully developing. This deficient practice

could affect over three staff and visitors.

Findings include:







08/10/18, the following was noted:

a. storage supply items were stored on shelving up

to the ceiling in the DME Room in the basement.

b. storage supply items were stored on shelving

two inches below the ceiling in the IVF storage

room in the basement.

c. items were stored on shelving six inches below

the ceiling by the refrigerator in the Andrology

Lab on the second floor.



agreed the spray pattern for ceiling mounted

sprinkler heads in the aforementioned rooms was

obstructed by shelf storage within 18 inches of the


center's facility

manager has corrected the door

latching mechanism.

1. Users of the supply room in

the basement and the second

floor were informed and educated

about maintaining 18 inches of

ceiling clearance in their storage

areas.

2. The facility manager and staff

were also informed about the

need for all sprinklers to have a

cover plate.






maintenance of the facility. The

life safety representative will

verify these conditions during

rounding.




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ceiling.


facility failed to ensure 1 of over 100 sprinkler

heads in the facility were installed in accordance

with NFPA 13. NFPA 13, Standard for the

Installation of Sprinkler Systems, 2010 Edition,

Section 6.2.7.2 states escutcheons used with

recessed, flush-type or concealed sprinklers shall

be part of a listed sprinkler assembly. This

deficient practice could affect one patient, staff

and visitors in the vicinity of second floor

Andrology Lab.

Findings include:







08/10/18, one of one recessed sprinklers in the

second floor Janitor's Closet by the Andrology

Lab was missing its cover plate. Based on

interview at the time of the observations, the

Building Engineer for HTA agreed the

aforementioned sprinkler location was missing its

cover plate.

NFPA 101

Sprinkler System - Maintenance and Testing

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.

K 0353

Bldg. 01





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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

1. Based on record review, observation and

interview; the facility failed to provide written

documentation or other evidence the sprinkler

system components had been inspected and tested

for 1 of 4 quarters. LSC 4.6.12.1 requires any

device, equipment or system required for

compliance with this Code be maintained in

accordance with applicable NFPA requirements.

Sprinkler systems shall be properly maintained in

accordance with NFPA 25, Standard for the

Inspection, Testing, and Maintenance of

Water-Based Fire Protection Systems. NFPA 25,

4.3.1 requires records shall be made for all

inspections, tests, and maintenance of the system

components and shall be made available to the

authority having jurisdiction upon request. 4.3.2

requires that records shall indicate the procedure

performed (e.g., inspection, test, or maintenance),

the organization that performed the work, the

results, and the date. NFPA 25, 5.2.5 requires

that waterflow alarm devices shall be inspected

quarterly to verify they are free of physical

damage. NFPA 25, 5.3.3.1 requires the

mechanical waterflow alarm devices including,

but not limited to, water motor gongs, shall be

tested quarterly. 5.3.3.2 requires vane-type and

pressure switch-type waterflow alarm devices

shall be tested semiannually. This deficient

practice could affect all patients, staff, and

visitors in the facility.


center's facility

manager has contracted with a

vendor to perform the following

corrections:

1. Ensure that quarterly

waterflow device testing

documentation is maintained on

site and made available upon

request.

2. Remove cabling affixed to the

sprinkler piping noted in the

statement of deficiencies.










09/21/2018 12:00:00AM





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Findings include:

Based on review of Koorsen Fire & Security

"Inspection and Test Report" documentation

dated 01/27/18, 04/28/18 and 08/04/18 with the






4:20 p.m. on 08/09/18, quarterly waterflow alarm

device testing documentation for the fourth

quarter (October, November, December) 2017

was not available for review. Based on

observations with the Director of ASC Clinical





to 2:10 p.m. on 08/10/18, hanging tags affixed to

the sprinkler system riser in the basement by

Koorsen documented waterflow alarm inspection

and testing within the most recent twelve month

period on 01/27/18, 04/28/18 and 08/04/18 but

not for the fourth quarter 2017. Based on

interview at the time of record review and of the


stated he was certain Koorsen conducted the

fourth quarter 2017 testing but agreed waterflow

alarm inspection and testing documentation for

the fourth quarter 2017 was not available for

review at the time of the survey.


facility failed to maintain 1 of 1 sprinkler systems

in accordance with NFPA 25. NFPA 25,

Standard for the Inspection, Testing, and

Maintenance of Water-Based Fire Protection

Systems, 2011 edition, Section 5.2.2.2 states

sprinkler piping shall not be subjected to external

loads by materials either resting on the pipe or





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hung from the pipe. This deficient practice could

affect over three staff and visitors in the

basement.

Findings include:







08/10/18, four data cables were affixed to a thirty

foot length of horizontal sprinkler pipe behind

AHU #2 in the basement. In addition, one white

data cable was wrapped around a sprinkler pipe in

the hallway outside the basement elevator

machine room. Based on interview at the time of


agreed the aforementioned sprinkler pipe

locations were used to support non-system

components.

NFPA 101

Sprinkler System - Out of Service

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.

K 0354

Bldg. 01





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9.7.5, 15.5.2 (NFPA 25)


failed to provide a complete written policy

containing procedures to be followed for the

protection of all patients in the event the

automatic sprinkler system has to be placed

out-of-service for 10 hours or more in a 24-hour

period in accordance with LSC, Section 9.7.5.

LSC 9.7.5 requires sprinkler impairment

procedures comply with NFPA 25, 2011 Edition,

the Standard for the Inspection, Testing and

Maintenance of Water-Based Fire Protection

Systems. NFPA 25, 2011 Edition, Section 15.5.2

requires the fire department, insurance carrier, the

alarm company, the property owner or designated

representative and other authorities having

jurisdiction be notified. This deficient practice


Findings include:

Based on review of "Emergency Response Plan:

Fire Watch - Incident Action Plan"







the fire watch plan for automatic sprinkler system

impairment was incomplete. The plan failed to

include contacting the Indiana State Department

of Health via the ISDH Gateway link at

https://gateway.isdh.in.gov as the primary method

or by the secondary method when the ISDH

Gateway is nonoperational by completing the

Incident Reporting form and e-mailing it to

[email protected]. In addition, the fire watch

plan for automatic sprinkler system impairment

failed to include notification of the alarm

monitoring company and the insurance carrier.





Gateway link at











annual review.



this deficiency.

08/27/2018 12:00:00AM














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the Director of ASC Clinical Operations agreed

the fire watch documentation for fire alarm

system impairment did not state to contact the

Indiana State Department of Health via the ISDH

Gateway link or at the e-mail address listed above

and also did not include notification of the alarm

monitoring company and the insurance carrier.

NFPA 101

Subdivision of Building Spaces - Smoke

Barrie

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.

21.3.7.5, 21.3.7.6, 8.5

K 0372

Bldg. 01


interview; the facility failed to ensure 2 of 2

smoke barriers which divide the suite into two

separate smoke compartments was constructed in

accordance with LSC Section 8.5 unless

otherwise permitted by Section 21.3.7.6. LSC

Section 8.5.6.2 states penetrations for cables,

conduits, pipes and similar items that pass

through a wall constructed as a smoke barrier

shall be protected by a system or material capable

of resisting 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 Section 8.3.5 to limit the

spread of fire for a time period equal to the fire

resistance of the assembly and Section 8.5.6.

This deficient practice could affect all patients



contracted with an outside

vendor to correct the

deficiencies. A quote was

recieved for the project on

8/30/2018.




ensure that any firewall

penetration is corrected properly.




09/23/2018 12:00:00AM





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and staff if smoke from a fire were to infiltrate the

protective barrier.

Findings include:






4:20 p.m. on 08/09/18, facility blueprint

documentation and facility construction type

documentation was not available for review.


the Building Engineer for HTA stated he obtained

the approximate square footage for each floor of

the surgery suite by telephone from his supervisor

at the time of the survey. The second and third

floor each measured, approximately, 14,463

square feet. Based on observations with the



of PACU Clinical Operations and with the

Building Engineer for Health Trust of America

(HTA) during a tour of the facility from 10:00

a.m. to 2:10 p.m. on 08/10/18, a one inch in

diameter hole was noted above the suspended

ceiling by the corridor smoke barrier door set by

Bay 1 on the third floor. In addition, the door in

the smoke barrier wall behind the nurse's station

in the operating room area on the second floor

failed to fully self close when tested to close

multiple times. Based on interview at the time of


stated the location of the hole and the door was in

required smoke barrier walls and agreed the

aforementioned openings in the smoke barrier

wall did not maintain the fire resistance rating of

the smoke barrier wall.

NFPA 101 K 0511





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Utilities - Gas and Electric

Utilities - Gas and Electric

Equipment using gas or related gas piping

complies with NFPA 54, National Fuel Gas

Code, electrical wiring and equipment

complies with NFPA 70, National Electric

Code. Existing installations can continue in

service provided no hazard to life.

20.5.1, 21.5.1, 21.5.1.2, 9.1.1, 9.1.2

Bldg. 01


failed to ensure all electrical wiring in the facility

was maintained in safe operating condition. LSC

21.5.1 requires utilities comply with Section 9.1.

LSC 9.1.2 requires electrical wiring and

equipment to comply with NFPA 70, National

Electrical Code. NFPA 70, 2011 Edition, Article

314 states exposed terminals and receptacles shall

be enclosed so that live wiring terminals are not

exposed to contact. This deficient practice could

affect one staff.

Findings include:







08/10/18, spliced electrical wiring above the

suspended ceiling above the corridor door set by

Bay 4 on the second floor was confined within a

junction box but the junction box was not

provided with a cover compatible with the box.



agreed the aforementioned junction box was not

provided with a cover compatible with the box.


center's facility manager will

provide a compatible cover for the

junction box noted above bay 4

on the second floor.




ensure that compliant work is

performed in the center.




09/15/2018 12:00:00AM

NFPA 101

HVAC

K 0521





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HVAC

Heating, ventilation, and air conditioning

shall comply with 9.2 and shall be installed in

accordance with the manufacturer's

specifications.

20.5.2.1, 21.5.2.1, 9.2

Bldg. 01


interview; the facility failed to ensure 100 % of

fire dampers in the facility were inspected and

provided necessary maintenance at least every

four years in accordance with NFPA 90A. LSC

9.2.1 requires heating, ventilating and air

conditioning (HVAC) ductwork and related

equipment shall be in accordance with NFPA

90A, Standard for the Installation of

Air-Conditioning and Ventilating Systems.

NFPA 90A, 2012 Edition, Section 5.4.8.1 states

fire dampers shall be maintained in accordance

with NFPA 80, Standard for Fire Doors and Other

Opening Protectives. NFPA 80, 2010 Edition,

Section 19.4.1 states each damper shall be tested

and inspected 1 year after installation. The test

and inspection frequency shall be every 4 years.

If the damper is equipped with a fusible link, the

link shall be removed for testing to ensure full

closure and lock-in-place if so equipped. The

damper shall not be blocked from closure in any

way. All inspections and testing shall be

documented, indicating the location of the fire

damper, date of inspection, name of inspector and

deficiencies discovered. The documentation shall

have a space to indicate when and how the

deficiencies were corrected. This deficient


visitors.

Findings include:





center's facility manager is

responsible to ensure that fire

dampers are tested, at the

required intervals, and that

documentation is maintained on

site of all testing.



will ensure compliance with this

requirement by utilizing his

building systems to track

completed work.




09/21/2018 12:00:00AM





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4:20 p.m. on 08/09/18, documentation of facility

fire damper inspection and maintenance within

the most recent four year period was not available

for review. Based on interview at the time of

record review, the Building Engineer stated the

facility has fire dampers but agreed

documentation of facility fire damper inspection

and maintenance within the most recent four year

period was not available for review. Based on

observations with the Director of ASC Clinical





to 2:10 p.m. on 08/10/18, two fire dampers were

noted in HVAC ductwork in the elevator machine

room in the basement and one fire damper was

noted in HVAC ductwork in the hallway outside

the basement elevator machine room. In addition,

fire dampers were also noted in the elevator shaft

in the atrium by the entrance to the Medical

Office Building. No inspection documentation

was affixed to any of the observed fire dampers.

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

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.

21.7.1.4 through 21.7.1.7

K 0712

Bldg. 01





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1. Based on record review and interview, the

facility failed to document activation of the fire

alarm system for second shift fire drills conducted

between 6:00 a.m. and 9:00 p.m. for 2 of 4

quarters. LSC 21.7.1.4 states fire drills in health

care occupancies shall include the transmission of

the fire alarm signal and simulation of emergency

fire conditions. When drills are conducted

between 9:00 p.m. (2100 hours) and 6:00 a.m.

(0600 hours), a coded announcement shall be

permitted to be used instead of audible alarms.

This deficient practice could affect all patients,

staff and visitors in the facility.

Findings include:

Based on review of "Code Red Drill Evaluation

Report" and "Fire Drill Participation Sign In"







documentation for second shift fire drills

conducted on 03/23/18 at 8:00 p.m. and on

05/11/18 at 7:55 p.m. each did not verify

activation of the fire alarm system and

transmission of the fire alarm signal. The

aforementioned documentation stated "Yes" in

response to "Was alarm signal received at alarm

monitoring office" but stated "N/A" in response to

"Were fire alarm chimes/bells and strobe lights

functional in the area" and in response to "Did

automatic fire doors close properly." Based on

interview at the time of record review, the

Building Engineer for HTA stated he can silence

the fire alarm system but still activates the fire

alarm system during daytime fire drills but was

not present for each of the two fire drills as they

were conducted after his shift time was over.

K 0712 Correction of deficit: Second

shift staff have been educated to

conduct second fire drills at

random times between 7pm and

7am. They have been educated

on the proper use of the drill

report sheet “Code Red Drill

Evaluation Report”. The sheets

“Evaluation of Building

Equipment” section will reflect

that an audible overhead

announcement was done and an

alarm signal was not sent to the

monitoring office. (See recent

second shift fire drill evaluation

form).


deficiency: The PACU manager

will ensure that drills are

performed in the first and second

shifts each quarter.

Responsible: The

clinical manager of PACU is

responsible for correction of this

deficiency.

08/27/2018 12:00:00AM





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the Manager of PACU Clinical Operations stated

the ASC staff are not familiar with silencing the

fire alarm system for fire drills and, as a result,

the fire alarm system was probably not activated

for these two fire drills conducted after 6:00 a.m.

but before 9:00 p.m.


facility failed to conduct quarterly fire drills at

unexpected times under varying conditions on the

first shift for 3 of 4 quarters. This deficient

practice could affect all patients, staff and visitors

in the facility.

Findings include:

Based on review of "Code Red Drill Evaluation

Report" and "Fire Drill Participation Sign In"







documentation for second shift fire drills

conducted on 12/10/17, 03/23/18 and 05/11/18

were conducted at, respectively, 7:00 p.m., 8:00

p.m. and 7:55 p.m. Based on interview at the

time of record review, the Manager of PACU

Clinical Operations stated the facility operates

two shifts per day, the second shift operates from

7:00 p.m. to 7:00 a.m., the facility likes to

perform fire drills during and after shift changes

and agreed the aforementioned second shift fire

drills were not conducted at varied times.

NFPA 101

Electrical Systems - Essential Electric Syste

Electrical Systems - Essential Electric

System Alarm Annunciator

K 0916

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A remote annunciator that is storage battery

powered is provided to operate outside of

the generating room in a location readily

observed by operating personnel. The

annunciator is hard-wired to indicate alarm

conditions of the emergency power source.

A centralized computer system (e.g.,

building information system) is not to be

substituted for the alarm annunciator.

6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)


failed to ensure 1 of 1 emergency generator

annunciator panels was in proper operating

condition. This deficient practice could affect all

the patients, staff and visitors.

Findings include:

Based on observations with the Manager of OR

Clinical Operations and the Manager of PACU

Clinical Operations during the initial walk

through of the facility from 9:50 a.m. to 10:15

a.m. on 08/09/10, the emergency generator's

remote annunciator panel located at the third floor

nurse's station had the "Not in Auto" (yellow)

light illuminated. The Manager of PACU Clinical

Operations stated the light is always illuminated

but facility maintenance staff has been able to

conduct emergency generator testing. The

emergency generator was not running at the time

of the survey. Based on observations with the



of PACU Clinical Operations and with the

Building Engineer for Health Trust of America

(HTA) during a tour of the facility from 10:00

a.m. to 2:10 p.m. on 08/10/18, the "Not in Auto"

(yellow) light for the emergency generator's

remote annunciator panel located was still

illuminated. Based on interview at the time of the




responsible to ensure that

facilities emergency generator

and support systems are

functioning correctly. The facility

manager is contracting with an

outside vendor for repair or

replacement the third floor panel.






completed work.




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stated the light is normally illuminated but the

emergency generator would start in the event of

normal power loss for the building.

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 four 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 consideration for new

installations.

6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110,

NFPA 111, 700.10 (NFPA 70)

K 0918

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facility failed to ensure the transfer time to the

alternate power source was capable of supplying

service within 10 seconds for monthly load tests

for 4 of the most recent 12 months. NFPA 99,

Health Care Facilities Code, 2012 Edition,

Section 6.4.4.1.1.1 states the generator set or

other alternate power source and associated

equipment, including all appurtenance parts shall

be so maintained as to be capable of supplying

service within the shortest time frame practicable

and within the 10 second interval specified in

6.4.1.1.10 and 6.4.3.1. This deficient practice


Findings include:

Based on record review from 10:15 a.m. to 4:20

p.m. on 08/09/18 with the Director of ASC




Care Trust of America (HTA), monthly load

testing documentation for 03/05/18, 05/07/18,

06/04/18, and 07/02/18 listed the transfer time as,

respectively, 15 seconds, 15 seconds, 18 seconds

and 39 seconds. Based on interview at the time of

record review, the Building Engineer for HTA

stated building power would be automatically

transferred to the generator in less than 10

seconds in the event of normal power loss but he

performs a manual start for monthly emergency

generator load testing and waits for normal power

to be stabilized before the transfer of power to the

generator and agreed transfer time documentation

for the aforementioned monthly load tests was

greater than 10 seconds.


facility failed to ensure 1 of 1 emergency

generators was equipped with a remote manual



responsible to ensure that

facilities emergency generator

and support systems are tested

and functioning correctly. The

facility manager is obtaining

quotes to install a remote manual

stop. The facility manager is also

coordinating with the center's

contracted service provider for

emergency generator support to

ensure appropriate transfer times.






completed work and testing.



correction of this deficiency

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stop in accordance with NFPA 99. NFPA 99,

Health Care Facilities Code, 2012 Edition,

Section 15.5.1.3 states emergency generators and

standby power system, where required for

compliance with this code, shall be installed,

tested, and maintained in accordance with NFPA

110, Standard for Emergency and Standby Power

Systems. NFPA 110, 2010 edition, 5.6.5.6 states

all installations shall have a remote manual stop

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. This

deficient practice could affect all patients, staff

and visitors.

Findings include:







08/10/18, the 125 kW emergency generator

located outside the facility was not equipped with

a remote manual stop. The date of manufacturer

of the generator could not be determined. Based

on interview at the time of the observations, the

Building Engineer for HTA stated the unit was

probably installed in or around 1994, there is a

remote manual stop inside the weatherproof shell

for the generator but there was no remote manual

stop station for the emergency generator.

NFPA 101

Electrical Equipment - Power Cords and

Extens

Electrical Equipment - Power Cords and

K 0920

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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


failed to ensure 2 of 2 extension cords including

power strips were not used as a substitute for

fixed wiring. LSC 21.5.1 requires utilities to

comply with Section 9.1. LSC 9.1.2 requires

electrical wiring and equipment to comply with

NFPA 70, National Electrical Code, 2011

Edition. NFPA 70, Article 400.8 requires that,

unless specifically permitted, flexible cords and

cables shall not be used as a substitute for fixed

wiring of a structure. LSC Section 4.5.7 states

any building service equipment or safeguard

provided for life safety shall be designed,

installed and approved in accordance with all

applicable NFPA standards. NFPA 99, Standard

for Health Care Facilities, 2012 edition, defines

patient care areas as any portion of a health care


facilities contracted clinical

engineering support team is

ensuring that all power strips

meet current code requirements.

Any power strip that cannot be

verified will be repalced.


deficiency: Clinical engineering

has been educated on this

requirement and will work with the

OR manager to ensure

compliance.

Responsible: The OR



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facility wherein patients are intended to be

examined or treated. Patient care vicinity is

defined as a space, within a location intended for

the examination and treatment of patients,

extending 6 ft (1.8 m) beyond the normal location

of the bed, chair, table, treadmill, or other device

that supports the patient during examination and

treatment. A patient care vicinity extends

vertically to 7 ft 6 in. (2.3 m) above the floor.

NFPA 99, Section 10.4.2.3 states household or

office appliances not commonly equipped with

grounding conductors in their power cords shall

be permitted provided they are not located within

the patient care vicinity. This deficient practice

could affect 2 patients and staff.

Findings include:







08/10/18, a power strip was affixed to a Stryker

elecrocauterizer medical device within the patient

care vicinity in Operating Room 3 and in

Operating Room 7. The UL listing of each power

strip was stated as "HC 16." Based on interview

at the time of the observations, the Manager of

OR Clinical Operations agreed power strips were

being used as a substitute for fixed wiring and in

the patient care vicinity.

NFPA 101

Gas Equipment - Cylinder and Container

Storag

Gas Equipment - Cylinder and Container

Storage

*Greater than or equal to 3,000 cubic feet

Storage locations are designed, constructed,

K 0923

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and ventilated in accordance with 5.1.3.3.2

and 5.1.3.3.3.

*Greater than 300 but less than 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 hour 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)


facility failed to ensure 1 of 1 indoor

nonflammable gas storage areas was enclosed



responsible to ensure that facility

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with a separation of 1 hour fire resistive

construction. NFPA 99, Standard for Health Care

Facilities, 2012 Edition, Section 11.3.1 states

storage for nonflammable gases equal to or

greater than 3000 cubic feet shall comply with

5.1.3.3.2 and 5.1.3.3.3. Section 5.1.3.3.2(2)

states they shall be secured with lockable doors or

gates or otherwise secured. Section 5.1.3.3.2(4)

states locations for central supply systems and the

storage of positive-pressure gases, if indoors,

shall be constructed and use interior finishes of

noncombustible or limited-combustible materials

such that all walls, floors, ceilings, and doors are

of a minimum 1-hour fire resistance rating. This


and visitors.

Findings include:







08/10/18, one liquid nitrogen storage container

listed as 160 liter capacity and four nitrogen

cylinders each with a capacity of 221.6 cubic feet

were noted in the second floor storage room by

the Andrology Lab. The corridor door set to the

storage room was not locked. The corridor door

set had no fire resistance rating label affixed and

each door in the door set was not equipped with a

self closing device to latch each door into the

door frame. In addition, a six inch in diameter

hole was noted in the wall of the room which

abuts the Andrology Lab. The hole had an open

ended PVC inserted in the hole and appeared to

be a passageway to supply nitrogen to the Lab.


observations, the Manager of OR Clinical

maintains code compliance. The

facility manager is obtaining

quotes to ensure the second floor

storage room maintains a 1 hour

rating. He is also coordinating

with the center's contracted

service provider to provide

outside venting for this room.






completed work and testing.








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Operations agreed the door set was not locked

and the room was not constructed with a

minimum 1-hour fire resistance rating.


facility failed to ensure 1 of 1 indoor

nonflammable gas storage areas was vented to the

outside. NFPA 99, Standard for Health Care

Facilities, Section 9.3.7.5 states indoor storage or

manifold areas and storage or manifold buildings

for medical gases shall be provided with natural

ventilation or mechanical ventilation in

accordance with 9.3.7.5.1 through 9.3.7.8. This


and visitors.

Findings include:







08/10/18, one liquid nitrogen storage container

listed as 160 liter capacity and four nitrogen

cylinders each with a capacity of 221.6 cubic feet

were noted in the second floor storage room by

the Andrology Lab. The medical gas systems

storage room was not vented to the outside.


observations, the Manager of OR Clinical

Operations agreed the medical gas systems

storage room was not vented to the outside.


e 0000 · 2018-11-20 · following the date of survey whether or not a plan of correction is...

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