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Based on observation and interview with staff, the facility failed to provide smoke barriers that are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. A minimum of two separate compartments are provided on each floor. Dampers are not required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems. 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4 Findings include:

1. The smoke wall penetrations on second floor were not sealed with material capable of maintaining the fire resistance of the fire barrier.

Based on observation , interview with staff, the facility failed to provide a written plan for the protection of all patients and for their evacuation in the event of an emergency. 19.7.1.1



Staff on the basement level, 2nd and 3rd floor were interviewed in the presence of the Director of Engineering. All three individuals in the building interviewed failed to demonstrate or explain the method adopted by the facility to use in case a fire was detected. The method adopted by the facility is RACE (RESCUE, ALARM, CONFINE, EXTINGUISH).

Fire Drill Documents used to track and document the readiness of staff to react in the event of a fire were not filled out completely. These documents shall be reviewed by the Safety Committee to make recommendations to the governing body and the effectiveness of staff to protect patient, staff, and visitors in case of an emergency.

Based on observation, interview with staff, the facility failed to provide Hospitals, and nursing homes and hospices with life support equipment, have a Type I Essential Electrical System powered by a generator with a transfer switch and separate power supply. The EES is in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4. Finding:

Battery back up lighting required over the transfer switches and the emergency generator were not installed . Lighting shall be supplied by a 90 minute battery back-up system, installed and maintained.

Based on observation, interview with staff, the facility failed to provide safety devices connected to the Boiler that provides utilities to the campus in accordance with NFPA 85. Findings include:

The Two Boilers located in the Basement of the Administration Building were not provided with Automatic Boiler Shut down switch outside the boiler room, which allows for manual shut down in an emergency in accordance with ASME CSD-1, reference from NFPA 85.

Based on observation and interview with staff, the facility failed to provide smoke barriers that are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. A minimum of two separate compartments are provided on each floor. Dampers are not required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems. 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4 Findings include:

1. The smoke wall penetrations on second floor were not sealed with material capable of maintaining the fire resistance of the fire barrier.

Based on observation , interview with staff, the facility failed to provide a written plan for the protection of all patients and for their evacuation in the event of an emergency. 19.7.1.1



Staff on the basement level, 2nd and 3rd floor were interviewed in the presence of the Director of Engineering. All three individuals in the building interviewed failed to demonstrate or explain the method adopted by the facility to use in case a fire was detected. The method adopted by the facility is RACE (RESCUE, ALARM, CONFINE, EXTINGUISH).

Fire Drill Documents used to track and document the readiness of staff to react in the event of a fire were not filled out completely. These documents shall be reviewed by the Safety Committee to make recommendations to the governing body and the effectiveness of staff to protect patient, staff, and visitors in case of an emergency.

Based on observation, interview with staff, the facility failed to provide Hospitals, and nursing homes and hospices with life support equipment, have a Type I Essential Electrical System powered by a generator with a transfer switch and separate power supply. The EES is in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4. Finding:

Battery back up lighting required over the transfer switches and the emergency generator were not installed . Lighting shall be supplied by a 90 minute battery back-up system, installed and maintained.

Based on observation, interview with staff, the facility failed to provide safety devices connected to the Boiler that provides utilities to the campus in accordance with NFPA 85. Findings include:

The Two Boilers located in the Basement of the Administration Building were not provided with Automatic Boiler Shut down switch outside the boiler room, which allows for manual shut down in an emergency in accordance with ASME CSD-1, reference from NFPA 85.