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Based on observation and interview with staff, the facility failed to provide an fire alarm system required for life safety that is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. Findings include:

A manually operated, electrically supervised fire alarm system was not installed in the Physical Therapy Building located north of the hospital .

Based on observation and interview with staff, the facility failed to provide and maintain Heating, ventilating, and air conditioning systems that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2 Findings include :

1) The fusible link fire dampers installed in the doors for return air grills were not on a preventive maintenance programmed and they were not cleaned and exercised.

Based on observation, interview with staff, the facility failed to provide a Piped in medical gas system, that comply's with NFPA 99, Chapter 4. Findings include:

1) The facility failed to provide a Emergency Piped in Oxygen Supply port in accordance with NFPA 99 1999 edition chapter 4-3.1.1.8 (h) .Where a cryogenic oxygen supply is located outside the building served, there shall be incorporated in the piping system and inlet to connect a temporary source for supply in an emergency.

Based on observation and interview with staff, the facility failed to provide Electrical wiring and equipment that is installed and maintained in accordance with NFPA 70, National Electrical Code. 9.1.2 Findings include:

1) The physical therapy building was not provided with Hospital Grade receptacles in patient care areas.

2) The receptacles in all patient care areas of the hospital were not on a programmed that provided Impedance Testing in accordance with NFPA 99 1999 edition chapter 3- 3.3.2.1 through 3-3.4.3. Patient care areas are required to be tested for voltage measurement + or - 20% of 1000 ohms at frequencies of 1000 HZ or less.

3) There is no night light at the foot of every patient bed. The night light located on the wall at the foot of every patient bed was removed, and sheet rock was put in its place.

4) The normal power disconnect located outside, next to the new emergency generator was not secured from the public, the shut off was not locked in the open position.

5) The facility installed a new emergency generator since the last survey; the emergency generator now supplies the entire facility, however there is no single line drawing that depicts supply and panels were not labeled, also there was no documentation for approval from Authority Having Jurisdiction . This surveyor could not identify Life Safety Branch, Critical Care Branch, Emergency Branch, nor could maintenance identify emergency power system installed. The Performance-Based Design Option out of NFPA 101 2000 Life Safety Code chapter 5.8.14 requires that anyone involved in the ownership or management of the building notify and document the following:
(1) The building was approved as a performance-based design
with certain specified design criteria and assumptions.
(2) Any remodeling, modification, renovation, change in use, or change in the established assumptions will require a re-evaluation and re-approval. The system shall be in accordance with NFPA 99 1999 edition chapter 3- 4.2.2.1 General Type 1 Emergency Electrical System.

Based on observation and interview with staff, the facility failed to provide an fire alarm system required for life safety that is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. Findings include:

A manually operated, electrically supervised fire alarm system was not installed in the Physical Therapy Building located north of the hospital .

Based on observation and interview with staff, the facility failed to provide and maintain Heating, ventilating, and air conditioning systems that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2 Findings include :

1) The fusible link fire dampers installed in the doors for return air grills were not on a preventive maintenance programmed and they were not cleaned and exercised.

Based on observation, interview with staff, the facility failed to provide a Piped in medical gas system, that comply's with NFPA 99, Chapter 4. Findings include:

1) The facility failed to provide a Emergency Piped in Oxygen Supply port in accordance with NFPA 99 1999 edition chapter 4-3.1.1.8 (h) .Where a cryogenic oxygen supply is located outside the building served, there shall be incorporated in the piping system and inlet to connect a temporary source for supply in an emergency.

Based on observation and interview with staff, the facility failed to provide Electrical wiring and equipment that is installed and maintained in accordance with NFPA 70, National Electrical Code. 9.1.2 Findings include:

1) The physical therapy building was not provided with Hospital Grade receptacles in patient care areas.

2) The receptacles in all patient care areas of the hospital were not on a programmed that provided Impedance Testing in accordance with NFPA 99 1999 edition chapter 3- 3.3.2.1 through 3-3.4.3. Patient care areas are required to be tested for voltage measurement + or - 20% of 1000 ohms at frequencies of 1000 HZ or less.

3) There is no night light at the foot of every patient bed. The night light located on the wall at the foot of every patient bed was removed, and sheet rock was put in its place.

4) The normal power disconnect located outside, next to the new emergency generator was not secured from the public, the shut off was not locked in the open position.

5) The facility installed a new emergency generator since the last survey; the emergency generator now supplies the entire facility, however there is no single line drawing that depicts supply and panels were not labeled, also there was no documentation for approval from Authority Having Jurisdiction . This surveyor could not identify Life Safety Branch, Critical Care Branch, Emergency Branch, nor could maintenance identify emergency power system installed. The Performance-Based Design Option out of NFPA 101 2000 Life Safety Code chapter 5.8.14 requires that anyone involved in the ownership or management of the building notify and document the following:
(1) The building was approved as a performance-based design
with certain specified design criteria and assumptions.
(2) Any remodeling, modification, renovation, change in use, or change in the established assumptions will require a re-evaluation and re-approval. The system shall be in accordance with NFPA 99 1999 edition chapter 3- 4.2.2.1 General Type 1 Emergency Electrical System.