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A) The provider has documented information that identifies the construction type of the 2002 and 2008 additions to the building as Type I (332) construction (as defined by NFPA 220). However, the 1960 through 1978 portions of the facility are identified as Type II (000) construction (unprotected non-combustible). Most of the Type II construction is not protected by a sprinkler system. The portions of this one story facility identified as Type II (000) construction do not comply with 19.1.6.2.

The provider indicated that they are repairing the above condition as they find it. The extent of this condition is not pervasive but is not known by the provider. The surveyor confirmed that random portions of the building have unprotected steel columns and beams that support the roof, above the ceilings.

Examples; include but are not limited to: middle of the Dining Room and the Administrative Secretary's Office (above a wall pilaster).

A) Based upon review of fire drill documentation for four quarters of 2009/2010, the surveyor finds that fire drills do not always comply with 19.7.1.2.

1) The surveyor observed that fire drills for the 1st Shift were conducted around 2:00PM without much variation. The surveyor finds that fire drills for the 1st Shift, during the four quarters reviewed were not conducted at varying times.

2) The Mobile MRI Unit is used for both outpatient and inpatient treatment. Fire drills are not conducted for this unit.

Update 05/06/11: The surveyor noted that documentations for future fire drills be continually reviewed during monitoring visits to verify that drills are being conducted in accordance with 19.7.1.2.

A) Based upon random observation the surveyor finds that the fire alarm system is not installed, tested and maintained in accordance with NFPA 72:

1) Strobes are not always synchronized in accordance with NFPA 72.

a) Two fire alarm strobes at the north end of the Obstetrics Unit skip (and do not flash) every fourth beat (every fourth flash, two devices do not flash when the others flash).

b) The fire alarm strobes in the corridor looking south (near Dietary) loose synchronization.

B) The facility has a Mobile MRI Unit that is used for inpatient treatment. The provider indicates that the fire alarm system within this Mobile Unit is tied directly to the Hospital's fire alarm system. The surveyors found no evidence that the fire alarm system, the fire alarm components and/or the tie in to the Hospital is tested, serviced and maintained in accordance with NFPA 72.

A) 1) Corrected 05/06/11.
2) Corrected 05/06/11.



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During the survey walk-through, not all portions of the facilities sprinkler system are installed in accordance with NFPA 13 1999.

Findings include:

A. The Maternity Department IT closet was observed without a sprinkler head installed and not in accordance with NFPA 101 2000 19.3.5.1.

Update 05/06/11: The surveyor observed that the IT closet lacks sprinkler protection to comply with Section 9.7.1.1 and shall be in accordance with NFPA 13, Standard for the Installation of sprinkler systems.

B. Corrected 05/06/11.

Based on document review during the survey process, not all portions of the facilities sprinkler system are tested and maintained in accordance with NFPA 25 1998.

Findings include:

A. Documents show semi-annual testing of flow switches not quarterly in accordance with Table 9.1

B. No documents to show quarterly testing of low air alarm on dry pipe system in accordance with Table 9.1..

C. No documentation to show 3 year full flow test on the dry pipe system in accordance with Table 9.1.