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Based on observation and interview on 12/07/11 with the Director of Maintenance, it was determined the facility failed to maintain the fire/smoke barrier walls to provide their required fire/smoke resistance rating. A fire/smoke barrier that is not maintained would in the event of fire allow fire, smoke and toxic gasses to migrate into adjacent smoke compartments, prolonging exposure to the buildings occupants. This poses potential for adverse effects to health and safety.

The findings include:

During the tour of the facility at 2:10 p.m., on the first floor above the drop ceiling, it was observed conduit passing through the rated wall. This conduit with wires inside was noted going into the operating room storage area. This penetration did not have the required fire chalking.

During the tour of the facility it was observed at 3:40 p.m., in the laboratory break room, above the drop ceiling, the fire/smoke barrier had improper penetrations passing through the rated wall. It was observed conduit with wires inside passing thru the rated wall. These penetrations did not have the required fire chalking.

Based on a review of the facility records and interview with the staff on 12/8/11, it was determined the facility failed to test the Fire Alarm Systemas frequently as required. This in the event of a malfunction could delay or deny the required early warning of an unsafe environment or fire.

The findings include:

There was no documentation at the time of the survey to show that the Fire Alarm System at the Northport offsite facility was tested in the last twelve months. The last certification of the alarm was 11/17/10, which expired 11/30/11.

The Administrative Support Manager acknowledged and confirmed the alarm testing was past due and further stated the contractor would not do the inspection until the contract for services was completed. She further stated it would not be inspected for another two weeks.

Based on a review of the facility records and interview with the staff on 12/8/11, it was determined the facility failed to test the Fire Alarm System as frequently as required. This in the event of a malfunction could delay or deny the required early warning of an unsafe environment or fire.

The findings include:

There was no documentation at the time of the survey to show the smoke detectors at the Northport offsite facility were tested for sensitivity in the last two years.

The Administrative Support Manager acknowledged and confirmed the alarm testing was past due and further stated the contractor would not do the inspection until the contract for services was completed. She further stated it would not be inspected for another two weeks.

1. Based on a review of the facility records and interview with the staff on 12/6/11, it was determined the facility failed to ensure the automatic fire sprinkler system at the main Campus was tested as frequently as required. This renders the equipment unreliable, and in the event of a malfunction during a fire could delay or deny extinguishment.


The findings include:

There was no documentation at the time of the survey to show the dry portion of the automatic fire sprinkler system was tested by a full flow trip test every third year as required by NFPA 25(1998 edition) chapter 9-1.


2. Based on observations made during tour of the Northport offsite facility on 12/8/11, it was determined the facility failed to ensure the fire sprinkler system was maintained in reliable operating condition. This could delay or deny complete sprinkler protection.

The findings include:

The Porte Cochere' at the offsite facility entrance was observed to have six sprinkler heads. The sprinkler heads were observed to be visibly loaded or corroded.

Based on a review of the facility records and interview with the staff, it was determined the facility failed to ensure the Heating, Ventilating, and Air Conditioning System (HVAC) was maintained in reliable operating condition.

The findings include:

Inspection of the main kitchen on 12/7/11 revealed there was a notable negative pressure relationship between the kitchen and the corridor housing the kitchen opening only on door to the kitchen yielded enough pressure to defeat the hydraulic door closure and keep the door open with significant cubic feet of corridor air entering the kitchen. It was noted the kitchen supply air was operable as well as the exhaust and make up hood air.

Based on observation and interview on 12/07/11 with the Director of Maintenance, it was determined the facility failed to maintain the fire/smoke barrier walls to provide their required fire/smoke resistance rating. A fire/smoke barrier that is not maintained would in the event of fire allow fire, smoke and toxic gasses to migrate into adjacent smoke compartments, prolonging exposure to the buildings occupants. This poses potential for adverse effects to health and safety.

The findings include:

During the tour of the facility at 2:10 p.m., on the first floor above the drop ceiling, it was observed conduit passing through the rated wall. This conduit with wires inside was noted going into the operating room storage area. This penetration did not have the required fire chalking.

During the tour of the facility it was observed at 3:40 p.m., in the laboratory break room, above the drop ceiling, the fire/smoke barrier had improper penetrations passing through the rated wall. It was observed conduit with wires inside passing thru the rated wall. These penetrations did not have the required fire chalking.

Based on a review of the facility records and interview with the staff on 12/8/11, it was determined the facility failed to test the Fire Alarm Systemas frequently as required. This in the event of a malfunction could delay or deny the required early warning of an unsafe environment or fire.

The findings include:

There was no documentation at the time of the survey to show that the Fire Alarm System at the Northport offsite facility was tested in the last twelve months. The last certification of the alarm was 11/17/10, which expired 11/30/11.

The Administrative Support Manager acknowledged and confirmed the alarm testing was past due and further stated the contractor would not do the inspection until the contract for services was completed. She further stated it would not be inspected for another two weeks.

Based on a review of the facility records and interview with the staff on 12/8/11, it was determined the facility failed to test the Fire Alarm System as frequently as required. This in the event of a malfunction could delay or deny the required early warning of an unsafe environment or fire.

The findings include:

There was no documentation at the time of the survey to show the smoke detectors at the Northport offsite facility were tested for sensitivity in the last two years.

The Administrative Support Manager acknowledged and confirmed the alarm testing was past due and further stated the contractor would not do the inspection until the contract for services was completed. She further stated it would not be inspected for another two weeks.

1. Based on a review of the facility records and interview with the staff on 12/6/11, it was determined the facility failed to ensure the automatic fire sprinkler system at the main Campus was tested as frequently as required. This renders the equipment unreliable, and in the event of a malfunction during a fire could delay or deny extinguishment.


The findings include:

There was no documentation at the time of the survey to show the dry portion of the automatic fire sprinkler system was tested by a full flow trip test every third year as required by NFPA 25(1998 edition) chapter 9-1.


2. Based on observations made during tour of the Northport offsite facility on 12/8/11, it was determined the facility failed to ensure the fire sprinkler system was maintained in reliable operating condition. This could delay or deny complete sprinkler protection.

The findings include:

The Porte Cochere' at the offsite facility entrance was observed to have six sprinkler heads. The sprinkler heads were observed to be visibly loaded or corroded.

Based on a review of the facility records and interview with the staff, it was determined the facility failed to ensure the Heating, Ventilating, and Air Conditioning System (HVAC) was maintained in reliable operating condition.

The findings include:

Inspection of the main kitchen on 12/7/11 revealed there was a notable negative pressure relationship between the kitchen and the corridor housing the kitchen opening only on door to the kitchen yielded enough pressure to defeat the hydraulic door closure and keep the door open with significant cubic feet of corridor air entering the kitchen. It was noted the kitchen supply air was operable as well as the exhaust and make up hood air.