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Based on observation and staff interview, the facility failed to provide 2-hour rated construction at the building separation walls in accordance with 2000 - NFPA 101, sections 19.1.1.4.1 and 8.2.3.2.

Findings include:

On facility tour between 8:00 AM on 09/04/2013 and 12:30 PM on 09/05/2013, observation revealed that the 1st floor - west link, 2 hour fire separation door did not drop on fire alarm from the hospital to the attached clinic. The fire alarm system from the hospital was not interconnect to the magnetic door hold open device.

This deficient practice was confirmed by Director of Facility Maintenance (EM) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain smoke-resisting partitions and doors in accordance with the following requirements of 2000 NFPA 101, Section 19.3.2.1.


Findings include:


On facility tour between 8:00 AM on 09/04/2013 and 12:30 PM on 09/05/2013, observation revealed that the following was found:

1. 2nd floor - storage room (over 50 sq ft.) # Fh 2-862, south door does not have an automatic closer

2. Lower level - auxiliary storage (over 50 sq. ft.) Fh LL-921 has (3) - 2 inch holes in south wall


These deficient practices were confirmed by Director of Facility Maintenance (EM) at the time of discovery.

Based on documentation review and staff interview, the facility failed to assure fire drills were conducted once per shift per quarter for all staff under varying times and conditions as required by 2000 NFPA 101, Section 19.7.1.2.


Findings include:

On facility tour between 8:00 AM on 09/04/2013 and 12:30 PM on 09/05/2013, the review of the fire drill documentation for the past 12 months (September 2012 to August 2013) revealed the drills for the following shifts were completed but did not sufficiently vary the times that the drills were conducted:

Day: 1347, 1106, 1315 and 1352 hours
Evening: 1720, 1710, 2128 and 1612 hours
Night: 0500, 0550, 0450 and 0445 hours

This deficient practice was confirmed by Director of Facility Maintenance (EM) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to test the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72 Tables 7-2.2 (16) (b).

Findings include:

On facility tour between 8:00 AM on 09/04/2013 and 12:30 PM on 09/05/2013, observation revealed that the following were found:

1. The primary and secondary transmission lines were tested by unplugging each phone line revealed, that there was no trouble signal with-in 4 minutes to the premises fire alarm system. It was verified that the monitoring company did receive both the trouble signal.

2. Smoke detectors are located with-in the air flow of supply or return vents at the following locations:
a. 1st floor - detectors # 123, 52 and 10-42
b. 2nd floor - 3-122

NOTE: Check the entire facility for # 2 deficiency


This deficient practice was confirmed by Director of Facility Maintenance (EM) at the time of discovery.

Based on observations and interview, the facility has compressed gas cylinders not properly stored in compliance with the requirements of NFPA 99.

Findings include:

On facility tour between 8:00 AM on 09/04/2013 and 12:30 PM on 09/05/2013, observation revealed that the following was found:

Medical gas room Fh LL-801:
1. Unsecured "H" cylinder - 1999 NFPA 99 - 4-3.5.2.1 (b) 27
2. No labeling of medical gas lines going through walls - 1999 NFPA 99 - 4-3.1.2.14


These deficient practices were confirmed by Director of Facility Maintenance (EM) at the time of discovery.

Based on observation and staff interview, the facility failed to install isolated power systems per 2000 NFPA 101 -19.3.2.3, 1999 NFPA 99 and 1999 NFPA 70.

Findings include:

On facility tour between 8:00 AM on 09/04/2013 and 12:30 PM on 09/05/2013, observation revealed that the following was found:

1. In Operating Rooms # 3 and OB "C" section does not have a isolated power system or ground fault interrupters. The Facilities Manager (EM) could not tell me if the operating rooms are considered wet or dry locations. 1999 NFPA 99 3-3.2.1 and 1999 NFPA 70 - Article 517-20(a).

2. In OB "C" section operating, no battery operated emergency lighting


These deficient practices were confirmed by Director of Facility Maintenance (EM) at the time of discovery.





*TEAM COMPOSITION*
Gary Schroeder, Life Safety Code Spc.