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LIFESTREAM BEHAVIORAL CENTER
Fire Alarm System - Testing and Maintenance
Tag No.: K0345
Based on record review and interviews the facility has failed to properly maintain their fire alarm system as required by NFPA 72 ( 2010 edition) chapter 14.4.5.3 and table 14.4.5 15 (a)
1. The 21 duct smoke detectors have not been tested for function
2. The 21 duct smoke detectors have not been tested for sensitivity.
NFPA 101 (2012 edition) chapter 9.6.1.3
Findings:
During record review January 10, 2017 the facility furnished documentation for an annual fire alarm inspection dated 05/18/2017 in which the fire alarm company did not document the function testing of 21 duct smoke detector with smoke. The facility also furnished documentation dated 10/11/2016 for the biennial sensitivity testing of smoke detectors which listed the duct smoke detectors as not tested.
During an interview on January 10, 2017 at 1:12 PM, with the Maintence Director who stated that the duct smoker detectors had not been teated.
Corridors - Construction of Walls
Tag No.: K0362
Based on observation and interviews, the facility has failed to maintain their fire resistive walls as required by NFPA 101 (2012 edition) chapter 8.3.5. Unsealed penetrations were observed above one set of corridor doors.
Findings:
While on tour January 10, 2017 at 1:12 PM an observation shows above the main corridor smoke doors separating the business section from the hospital, there are unsealed penetrations observed.
During an interview on January 10, 2017 at 1:12 PM, with the Maintenance Director stated he has acknowledged the unsealed penetrations observed on tour.
Electrical Systems - Essential Electric Syste
Tag No.: K0918
Based on record review and interviews the facility failed to properly maintain their emergency generator. The facility failed the document the monthly testing of the emergency generator's battery's electrolyte specific gravity as required by NFPA 110 (2010 edition) chapter 8.3.7.1.
NFPA 101 (2012 edition) chapter 9.1.3.1
Finding:
During record review January 10, 2017 the facility furnished documentation for the monthly testing of their emergency generator which did not include the testing of the battery's electrolytes specific gravity.
During an interview on January 10, 2017 at 1:12 PM, the Maintenance Director acknowledge the electrolytes had not been tested.