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SHRINERS HOSPITAL FOR CHILDREN
Fire Alarm System - Testing and Maintenance
Tag No.: K0345
Based on surveyor review of the facility's maintenance records and interview with the facility's Safety and Security Coordinator, on 3.16.17 at approximately 10:00A; the facility failed to maintain the fire alarm system in accordance with Section 9.6, 9.6.1.3, NFPA 70 (2011 Ed.) & NFPA 72 (2010 Ed.).
The facility's Safety and Security Coordinator was unable to produce documentation that the fire alarm system was inspected, tested & maintained annually by qualified personnel in accordance with NFPA 72 (2010 Ed.), National fire Alarm Code, Section 10.4.3 and Section 14.2.2.5.
The facility's Safetyand Security Coordinator was unable to produce an annual report from a licensed, certified, independent third party contractor or vender that the facility's fire alarm system was inspected, tested and maintained annually in accordance with NFPA 72.
The annual inspection, testing and maintenance of the facility's fire alarm system was performed in house by the facility's Safety and Security Coordinator.
Sprinkler System - Maintenance and Testing
Tag No.: K0353
Based on surveyor review of the facility's maintenance records and interview with the facility's Safety and Security Coordinator, on 3.16.17 at approximately 10:00A; the facility failed to maintain the automatic fire sprinkler system in accordance with Section; 19.3.5.3, 9.7.5, 9.7.7, 9.7.8 and NFPA 25 (2011) Section 5.1.1.
The facility's Safety Officer and Security Coordinator was unable to produce documentation that the automatic fire sprinkler system was inspected, tested and maintained annually by qualified personnel in accordance with NFPA 25 (2011) Section 5.1.1.
The facility's Safety Officer was unable to produce an annual report produced by a licensed, certified, independent third party contractor or vender that the facility's fire alarm system was inspected, tested and maintained annually in accordance with NFPA 25 (2011).
The annual inspection, testing and maintenance of the facility's fire alarm system was performed in house by the facility's Safety and Security Coordinator.
Fundamentals - Building System Categories
Tag No.: K0901
Based on surveyor review of the facility's maintenance records and interview with the facility's Safety and Security Coordinator, on 3.16.17 at approximately 10:00A; the facility failed to meet the requirements of NFPA 99 (2012), Health Care Facilities Code, Chapter 4; Fundamentals.
The facility's Safety and Security Coordinator was unable to provide a documented "Risk Assessment Procedure" in accordance with NFPA 99; Chapter 4.