HospitalInspections.org

.
The facility failed to provide complete corridor walls. See example:


A pass-through window with an opening more than eighty square inches, approximately four inches wide and forty-eight inches high, above half the distance from the floor to the room ceiling and in a smoke compartment containing patient bedrooms was observed at the Front Lobby Office. This room was observed without smoke detection coverage.

------------
NFPA 101, 18.3.6.1 Corridors shall be separated from all other areas by partitions complying with 18.3.6.2 through 18.3.6.5. (See also 18.2.5.9.)
Exception No. 1: Spaces shall be permitted to be unlimited in area and open to the corridor, provided that the following criteria are met:
(a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.
(b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers.
(c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses ' station or similar space.
(d) The space does not obstruct access to required exits.

.
The facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke. See examples:


Unsealed conduit and duct penetrations were observed in the smoke barrier above the ceiling in the Med Room.

------------
NFPA 101, 18.3.7.3 and 8.3.1 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour.

.
The facility failed to maintain self-closing doors in smoke barriers. See examples:


The cross corridor smoke doors were observed with the latching hardware, original equipment, in the locked position preventing the doors from latching in the frame.

------------
NFPA 101, 18.3.7.6, 8.3.4 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 18.2.2.2.6.

NFPA 101, 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

.
The facility failed to maintain fire and smoke-resisting partitions for hazardous areas. See example:


An unsealed opening at a beam was observed above the ceiling in the Medical Records Room.

------------
NFPA 101, 18.3.2.1 and 8.4.1 Any hazardous area shall be protected in accordance with Section 8.4.

.
The facility failed to provide readily accessible exit access. See examples:


1) The cross corridor sliding glass door failed to push open without electrical current due to the carpet and threshold preventing opening.

2) A key for the lock on the exit gate from the Courtyard was not readily available or carried by staff.

3) A sign identifying the switch as the Emergency Release Switch at the Nursing Station was not provided.

------------
NFPA 101, 18.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.

NFPA 101, 7.1.10 and 7.5.1.1 Exit access shall be arranged so that exits are readily accessible at all times.

NFPA 101, 7.2.1.4.1 Any door in a means of egress shall be of the side-hinged or pivoted-swinging type. The door shall be designed and installed so that it is capable of swinging from any position to the full required width of the opening in which it is installed.

NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
Exception No. 2: Exterior doors shall be permitted to have key-operated locks from the egress side, provided that the following criteria are met:
(d) A key is immediately available to any occupant inside the building when it is locked.

Alabama Department of Public Health Memo "Exit Door Locking Arrangements in Health Care
Facilities" revised 8/23/2011, as authority having jurisdiction: a manual release switch shall be provided on both sides of each locked door (required only on the indoor side of exterior doors).
An "emergency release switch" or "dead man" release switch shall be provided at the nearest nurse's station. There shall also be a sign at each door and nurse's station release switch indicating the door switch.

.
The facility failed to provide a complete evacuation plan in the event of emergency. See examples:


Based on interviews and observations during the survey, the fire evacuation plan did not include such items as the following:
a) Smoke compartment evacuation
b) Activation of alarms
c) Designated fire department caller

------------
NFPA 101, NFPA 18.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center. The provisions of 18.7.1.2 through 18.7.2.3 shall apply.

NFPA 101, 18.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire

.
The facility failed to maintain the fire alarm system in proper working order. See examples:


1) All facility staff did not have a key readily available to activate the locked fire alarm pull stations in the facility. See examples, pull station by:
a) Housekeeper
b) Administrator
c) Two Admin staff members

2) A Record Completion for the new fire alarm system was not provided by the facility during the survey.

------------
1999 NFPA 72, 7-5.1 Permanent Records After successful completion of acceptance tests approved by the authority having jurisdiction, a set of reproducible as-built installation drawings, operation and maintenance manuals, and a written sequence of operation shall be provided to the building owner or the owner ' s designated representative. The owner shall be responsible for maintaining these records for the life of the system for examination by any authority having jurisdiction. Paper or electronic media shall be permitted.

1999 NFPA 72, 1-6.2.1 A record of completion (Figure 1-6.2.1) shall be prepared for each system. Parts 1, 2, and 4 through 10 shall be completed after the system is installed and the installation wiring has been checked. Part 3 shall be completed after the operational acceptance tests have been completed. A preliminary copy of the record of completion shall be given to the system owner and, if requested, to other authorities having jurisdiction after completion of the installation wiring tests. A final copy shall be provided after completion of the operational acceptance tests.

1999 NFPA 72, 7-5.2.2 and Figure 7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be maintained which includes periodic tests and applicable information.

.
The facility failed to monitor the sprinkler system as required. See example:


Through interview and observation with facility staff, the surveyor was told the Sprinkler Pit served the Hospital and Skilled Nursing Facility. The tampers on the valves only sounded in the Skilled Nursing Facility and not in the Hospital.

------------
NFPA 101, 18.3.5.1 and 9.7.2.1; 1999 NFPA 13, 5-14.1.1.3; and 1999 NFPA 72, 2-9.1 Sprinkler control valves shall be electrically supervised so that at least a local alarm will sound at a constantly attended location when the valve is turned.

.
The facility failed to maintain the sprinkler system. See examples:


1) The last documentation for the sprinkler system provided by the facility was dated 4/18/2012 for the Above Ground Testing. Quarterly inspection documentation was not provided.

2) A large copper grounding wire was observed connected to the main riser pipe above the floor.

3) The FDC sign was not provided.

------------
NFPA 101, 9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

1999 NFPA 13, 12-1 General A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25.

NFPA 101, 9.7.5, and 1999 NFPA 25, 2-2 and Table 2-1 Inspection, Testing, Maintenance

1999 NFPA 13, 5-14.4.3.5 In no case shall the pipe be used for grounding of electrical services.

NFPA 25, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

.
The facility failed to provide means of emergency access to fire extinguishers. See example:


Through observation and interview, the surveyor observed the fire extinguisher cabinets to be locked, with the key to the fire extinguisher cabinets maintained in the Charting Room. Per interview each staff member does not keep a key on them to open the fire extinguisher cabinets.

------------
NFPA 10, 1-6.5 Cabinets housing fire extinguishers shall not be locked.
Exception: Where fire extinguishers are subject to malicious use, locked cabinets shall be permitted to be used, provided they include means of emergency access.

.
The facility failed to maintain smoking areas. See examples:


A metal container with a self-closing cover device into which ashtrays can be emptied was not provided on the Loading Dock where ash trays with smoking materials were observed.

------------
NFPA 101, 19.7.4 Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(2) Smoking by patients classified as not responsible shall be prohibited.
Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision.
(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

.
The facility failed to maintain curtains per code. Examples are as follows:

Documentation of flame resistance for the fabric shower curtains in the following areas was not provided during the survey:
a) Bath 1
b) Bath 2

------------
2000 NFPA 101, 10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

.
The facility failed to provide proper storage of oxygen cylinders. See example:


An E cylinder was observed in the full oxygen rack with gauges attached.

------------
CGA G-4, 4.1.10, and 1999 NFPA 99, 4-3.5.2.2(b)2 and 4-5.5.2.2(b)2 Full and empty cylinders shall be stored separately, with appropriate signage.

Alabama Department of Public Health Memo dated 11/24/04, Health Care Facility Oxygen
Storage Requirements, d.2. Gauges are not permitted on stored cylinders.

.
1) The facility failed to provide proper emergency lighting at the generator transfer controls. See example:

Battery-powered lighting at the generator equipment controls in the Basement failed to operate when tested.

------------
1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting.


2) The protective posts for the generator was observed not installed, post were lying next to the generator. The facility had installation of the posts started while the surveyor was on site.

------------
NFPA 110, 5-2.4 Consideration shall be given to the location of the Level 1 and Level 2 EPSS equipment to minimize the possibility of damage resulting from interruptions of the emergency power source caused by the following:
(a) * Natural conditions such as storms, floods, earthquakes, tornadoes, hurricanes, lightning, ice storms, wind, and fire
(b) Conditions such as vandalism, sabotage, and other similar occurrences
(c) Material and equipment failures

.
The facility failed to meet the requirements for the testing of the generator. See examples:


The facility failed to provide documentation of weekly inspections prior to 7/31/2012. The first patient was admitted 7/27/2012 according to interview with facility staff.

------------
The generator shall meet the requirements outlined in NFPA 99, 3-4.4.1 and NFPA 110.

NFPA 110, 6-3.4 A written record of inspections, tests, exercising, operation, and repairs shall be maintained.

NFPA 101, 18.2.9.1, 7.9 and NFPA 110, 6-4.1 Weekly inspection of the generator.

.
The facility failed to provide a complete plan in case of fire alarm system shutdown. See examples


Based on interviews and observations during the survey, the fire watch plan did not include such items as the following:
a) Approval from Fire Marshall / local fire authority
b) A designated person for the fire watch activity
c) Faxing logs

------------
NFPA 101, 9.6.1.8 Where a required fire alarm system is out of service for more than 4-hours in a 24-hour period, an approved fire watch shall be provided or the building shall be evacuated.

.
The facility failed to provide complete corridor walls. See example:


A pass-through window with an opening more than eighty square inches, approximately four inches wide and forty-eight inches high, above half the distance from the floor to the room ceiling and in a smoke compartment containing patient bedrooms was observed at the Front Lobby Office. This room was observed without smoke detection coverage.

------------
NFPA 101, 18.3.6.1 Corridors shall be separated from all other areas by partitions complying with 18.3.6.2 through 18.3.6.5. (See also 18.2.5.9.)
Exception No. 1: Spaces shall be permitted to be unlimited in area and open to the corridor, provided that the following criteria are met:
(a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.
(b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers.
(c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses ' station or similar space.
(d) The space does not obstruct access to required exits.

.
The facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke. See examples:


Unsealed conduit and duct penetrations were observed in the smoke barrier above the ceiling in the Med Room.

------------
NFPA 101, 18.3.7.3 and 8.3.1 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour.

.
The facility failed to maintain self-closing doors in smoke barriers. See examples:


The cross corridor smoke doors were observed with the latching hardware, original equipment, in the locked position preventing the doors from latching in the frame.

------------
NFPA 101, 18.3.7.6, 8.3.4 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 18.2.2.2.6.

NFPA 101, 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

.
The facility failed to maintain fire and smoke-resisting partitions for hazardous areas. See example:


An unsealed opening at a beam was observed above the ceiling in the Medical Records Room.

------------
NFPA 101, 18.3.2.1 and 8.4.1 Any hazardous area shall be protected in accordance with Section 8.4.

.
The facility failed to provide readily accessible exit access. See examples:


1) The cross corridor sliding glass door failed to push open without electrical current due to the carpet and threshold preventing opening.

2) A key for the lock on the exit gate from the Courtyard was not readily available or carried by staff.

3) A sign identifying the switch as the Emergency Release Switch at the Nursing Station was not provided.

------------
NFPA 101, 18.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.

NFPA 101, 7.1.10 and 7.5.1.1 Exit access shall be arranged so that exits are readily accessible at all times.

NFPA 101, 7.2.1.4.1 Any door in a means of egress shall be of the side-hinged or pivoted-swinging type. The door shall be designed and installed so that it is capable of swinging from any position to the full required width of the opening in which it is installed.

NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
Exception No. 2: Exterior doors shall be permitted to have key-operated locks from the egress side, provided that the following criteria are met:
(d) A key is immediately available to any occupant inside the building when it is locked.

Alabama Department of Public Health Memo "Exit Door Locking Arrangements in Health Care
Facilities" revised 8/23/2011, as authority having jurisdiction: a manual release switch shall be provided on both sides of each locked door (required only on the indoor side of exterior doors).
An "emergency release switch" or "dead man" release switch shall be provided at the nearest nurse's station. There shall also be a sign at each door and nurse's station release switch indicating the door switch.

.
The facility failed to provide a complete evacuation plan in the event of emergency. See examples:


Based on interviews and observations during the survey, the fire evacuation plan did not include such items as the following:
a) Smoke compartment evacuation
b) Activation of alarms
c) Designated fire department caller

------------
NFPA 101, NFPA 18.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center. The provisions of 18.7.1.2 through 18.7.2.3 shall apply.

NFPA 101, 18.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire

.
The facility failed to maintain the fire alarm system in proper working order. See examples:


1) All facility staff did not have a key readily available to activate the locked fire alarm pull stations in the facility. See examples, pull station by:
a) Housekeeper
b) Administrator
c) Two Admin staff members

2) A Record Completion for the new fire alarm system was not provided by the facility during the survey.

------------
1999 NFPA 72, 7-5.1 Permanent Records After successful completion of acceptance tests approved by the authority having jurisdiction, a set of reproducible as-built installation drawings, operation and maintenance manuals, and a written sequence of operation shall be provided to the building owner or the owner ' s designated representative. The owner shall be responsible for maintaining these records for the life of the system for examination by any authority having jurisdiction. Paper or electronic media shall be permitted.

1999 NFPA 72, 1-6.2.1 A record of completion (Figure 1-6.2.1) shall be prepared for each system. Parts 1, 2, and 4 through 10 shall be completed after the system is installed and the installation wiring has been checked. Part 3 shall be completed after the operational acceptance tests have been completed. A preliminary copy of the record of completion shall be given to the system owner and, if requested, to other authorities having jurisdiction after completion of the installation wiring tests. A final copy shall be provided after completion of the operational acceptance tests.

1999 NFPA 72, 7-5.2.2 and Figure 7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be maintained which includes periodic tests and applicable information.

.
The facility failed to monitor the sprinkler system as required. See example:


Through interview and observation with facility staff, the surveyor was told the Sprinkler Pit served the Hospital and Skilled Nursing Facility. The tampers on the valves only sounded in the Skilled Nursing Facility and not in the Hospital.

------------
NFPA 101, 18.3.5.1 and 9.7.2.1; 1999 NFPA 13, 5-14.1.1.3; and 1999 NFPA 72, 2-9.1 Sprinkler control valves shall be electrically supervised so that at least a local alarm will sound at a constantly attended location when the valve is turned.

.
The facility failed to maintain the sprinkler system. See examples:


1) The last documentation for the sprinkler system provided by the facility was dated 4/18/2012 for the Above Ground Testing. Quarterly inspection documentation was not provided.

2) A large copper grounding wire was observed connected to the main riser pipe above the floor.

3) The FDC sign was not provided.

------------
NFPA 101, 9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

1999 NFPA 13, 12-1 General A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25.

NFPA 101, 9.7.5, and 1999 NFPA 25, 2-2 and Table 2-1 Inspection, Testing, Maintenance

1999 NFPA 13, 5-14.4.3.5 In no case shall the pipe be used for grounding of electrical services.

NFPA 25, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

.
The facility failed to provide means of emergency access to fire extinguishers. See example:


Through observation and interview, the surveyor observed the fire extinguisher cabinets to be locked, with the key to the fire extinguisher cabinets maintained in the Charting Room. Per interview each staff member does not keep a key on them to open the fire extinguisher cabinets.

------------
NFPA 10, 1-6.5 Cabinets housing fire extinguishers shall not be locked.
Exception: Where fire extinguishers are subject to malicious use, locked cabinets shall be permitted to be used, provided they include means of emergency access.

.
The facility failed to maintain smoking areas. See examples:


A metal container with a self-closing cover device into which ashtrays can be emptied was not provided on the Loading Dock where ash trays with smoking materials were observed.

------------
NFPA 101, 19.7.4 Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(2) Smoking by patients classified as not responsible shall be prohibited.
Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision.
(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

.
The facility failed to maintain curtains per code. Examples are as follows:

Documentation of flame resistance for the fabric shower curtains in the following areas was not provided during the survey:
a) Bath 1
b) Bath 2

------------
2000 NFPA 101, 10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

.
The facility failed to provide proper storage of oxygen cylinders. See example:


An E cylinder was observed in the full oxygen rack with gauges attached.

------------
CGA G-4, 4.1.10, and 1999 NFPA 99, 4-3.5.2.2(b)2 and 4-5.5.2.2(b)2 Full and empty cylinders shall be stored separately, with appropriate signage.

Alabama Department of Public Health Memo dated 11/24/04, Health Care Facility Oxygen
Storage Requirements, d.2. Gauges are not permitted on stored cylinders.

.
1) The facility failed to provide proper emergency lighting at the generator transfer controls. See example:

Battery-powered lighting at the generator equipment controls in the Basement failed to operate when tested.

------------
1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting.


2) The protective posts for the generator was observed not installed, post were lying next to the generator. The facility had installation of the posts started while the surveyor was on site.

------------
NFPA 110, 5-2.4 Consideration shall be given to the location of the Level 1 and Level 2 EPSS equipment to minimize the possibility of damage resulting from interruptions of the emergency power source caused by the following:
(a) * Natural conditions such as storms, floods, earthquakes, tornadoes, hurricanes, lightning, ice storms, wind, and fire
(b) Conditions such as vandalism, sabotage, and other similar occurrences
(c) Material and equipment failures

.
The facility failed to meet the requirements for the testing of the generator. See examples:


The facility failed to provide documentation of weekly inspections prior to 7/31/2012. The first patient was admitted 7/27/2012 according to interview with facility staff.

------------
The generator shall meet the requirements outlined in NFPA 99, 3-4.4.1 and NFPA 110.

NFPA 110, 6-3.4 A written record of inspections, tests, exercising, operation, and repairs shall be maintained.

NFPA 101, 18.2.9.1, 7.9 and NFPA 110, 6-4.1 Weekly inspection of the generator.

.
The facility failed to provide a complete plan in case of fire alarm system shutdown. See examples


Based on interviews and observations during the survey, the fire watch plan did not include such items as the following:
a) Approval from Fire Marshall / local fire authority
b) A designated person for the fire watch activity
c) Faxing logs

------------
NFPA 101, 9.6.1.8 Where a required fire alarm system is out of service for more than 4-hours in a 24-hour period, an approved fire watch shall be provided or the building shall be evacuated.