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The facility failed to maintain the building construction type per code. Findings include:

During the revisit, based on interview with the Maintenance Director the architect is working on correction for this tag, the facility has a wavier approved until 10/31/2012.
First Floor
Same Day Surgery entrance/exit foyer was missing part of the two hour fire barrier above the lay-in ceiling.

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2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
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27382


The facility failed to provide a fire alarm system per code. Findings include:

During the revisit, based on interview with the Maintnance Director bids are being attain by the facility for cost of correction, facility has a waiver approved until 10/31/2012.

1. The surveyor could not verify that the fire alarm system was on a dedicated circuit

2. While testing the fire alarm system phone lines (DACT):

a. The facility did not get a trouble for line two
b. The facility did not get a trouble for both phone lines (communication)

1999 NFPA 72, Table 7-2.2
b. Digital Alarm Communicator Transmitter (DACT)
The primary line from the DACT shall be disconnected. Indication of the DACT trouble signal at the premises shall be verified as well as transmission to the supervising station within 4 minutes of detection of the fault.
The secondary means of transmission from the DACT shall be disconnected. Indication of the DACT trouble signal at the premises shall be verified as well as transmission to the supervising station within 4 minutes of detection of the fault.
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Second Floor
3. The surveyor could verify that the Geri-Psych doors released under loss of primary power to the fire alarm system

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NFPA 101 Sections 19.3.4.1 and 9.6. The indication shall be an audible and visual notification at location where it is likely to be heard in the facility.

1999 NFPA 72, 1-5.2.5.2 Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

1999 NFPA 72, Table 7-2.2 b. Digital Alarm Communicator
Transmitter (DACT)
The primary line from the DACT shall be disconnected. Indication of the DACT trouble signal at the premises shall be verified as well as transmission to the supervising station within 4 minutes of detection of the fault.

The secondary means of transmission from the DACT shall be disconnected. Indication of the DACT trouble signal at the premises shall be verified as well as transmission to the supervising station within 4 minutes of detection of the fault.

1999 NFPA 72, 3-9.7.3 All exits connected in accordance with 3-9.7.1 shall unlock upon loss of the primary power to the fire alarm system serving the protected premises. The secondary power supply shall not be utilized to maintain these doors in the locked condition.
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.

The facility failed to provide a fire alarm system per code. Findings include:

During the revisit, based on interview with the Maintnance Director bids are being attain by the facility for cost of correction, facility has a waiver approved until 10/31/2012.

1. The surveyor could not verify that the fire alarm system was on a dedicated circuit

2. While testing the fire alarm system phone lines (DACT):

a. The facility did not get a trouble for line two
b. The facility did not get a trouble for both phone lines (communication)

1999 NFPA 72, Table 7-2.2
b. Digital Alarm Communicator Transmitter (DACT)
The primary line from the DACT shall be disconnected. Indication of the DACT trouble signal at the premises shall be verified as well as transmission to the supervising station within 4 minutes of detection of the fault.
The secondary means of transmission from the DACT shall be disconnected. Indication of the DACT trouble signal at the premises shall be verified as well as transmission to the supervising station within 4 minutes of detection of the fault.
.
Second Floor
3. The surveyor could verify that the Geri-Psych doors released under loss of primary power to the fire alarm system

________________________
NFPA 101 Sections 19.3.4.1 and 9.6. The indication shall be an audible and visual notification at location where it is likely to be heard in the facility.

1999 NFPA 72, 1-5.2.5.2 Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

1999 NFPA 72, Table 7-2.2 b. Digital Alarm Communicator
Transmitter (DACT)
The primary line from the DACT shall be disconnected. Indication of the DACT trouble signal at the premises shall be verified as well as transmission to the supervising station within 4 minutes of detection of the fault.

The secondary means of transmission from the DACT shall be disconnected. Indication of the DACT trouble signal at the premises shall be verified as well as transmission to the supervising station within 4 minutes of detection of the fault.

1999 NFPA 72, 3-9.7.3 All exits connected in accordance with 3-9.7.1 shall unlock upon loss of the primary power to the fire alarm system serving the protected premises. The secondary power supply shall not be utilized to maintain these doors in the locked condition.
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The facility failed to perform the required maintenance of the facility sprinkler system. Findings include: During the revisit, based on interview with the Maintenance Director a quote has been received for replacement of osy valves, facility has a waiver approved until 10/31/2012.

Quarterly inspection conducted on 5/31/12, noted deficiencies, two OSY 4" were corroded located in the basement. Also bad flow switch Third Floor Stairwell.


NFPA 101,2000 Edition, 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this code shall be inspected, tested, and maintained in accordance with NFPA 25, Standards for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.