HospitalInspections.org

1) Based on observation and interview with staff, the facility failed to provide with a means suitable for keeping the door closed in its frame ( Latching Hardware) in accordance with 19.3.6.3

a) Latching hardware was removed from doors to room 110 and 111.

1) Based on observation and interview with staff, the facility failed to conduct Fire drills that are held at unexpected times under varying conditions, at least quarterly on each shift in accordance with 19.7.1.2. Findings include:

a) Fire Drills conducted was documented and stated that the area of refuge/ space to exit to was outside of the building. Staff was not trained to horizontally move from one smoke zone to the other. The last option should be to relocate outside.

b) At the bottom of all the Fire Drill Reports, there is a space for follow up. On most all of the Drills, follow up had not taken place and most did not have signatures.

1) Based on observation and interview with staff, the facility failed to provide a fire alarm installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. Findings include:

a) Smoke detectors located in the Dinning Room, Lobby and inside the room just north of the combination fire and smoke wall are located in the airstream of the HVAC Supply Grill, preventing the detector from detecting smoke.

b) Annual Fire Alarm Report was not signed by the Technician or Owner Representative. The report was faxed and the facility was not briefed on the report.

c) Annual report provided for review and used for documentation of the Annual Report does not meet the minimum requirements in accordance with NFPA 72 chapter 7-5.2.2. 1999 EDITION.

1) Based on observation and interview with staff, the facility failed to properly maintained and test the automatic sprinkler system automatic sprinkler system, Standard for the Installation of Sprinkler Systems.

a) The annual test conducted by Fire Troll on February 19, 2014 was faxed back to the facility, the report failed to have signatures of the inspector and the owners representative. The vendor did not explain results of the test with the owner's representative.

1) Based on observation and interview with staff, the facility failed to provide Heating, ventilating, and air conditioning systems that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2

a) 3 exhaust fans on the roof were burnt out and not working. The fourth had a motor that was very hot and turning very slow. Preventive maintenance Program did not include Exhaust Fans.

b) The facility did not have a HVAC commissioning report ( Test and Balance Report for Indoor air quality) that depicted air exchanges in patient rooms and treatment rooms.

1) Based on observation, interview with staff, and review of the Generator Logs provided by the facility, the facility failed to inspected the Generator weekly and exercised it under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1.

a) The Generator Log failed to have the Name Plate Rating/ Size.

b) The Generator log failed to have the % of load documented.

c) The Generator log failed to have an Log Sheet signed by the operator and reviewed by the Governing Body/ Reviewers Signature as required by the Log Sheet and adopted by the facility.

1) Based on observation and interview with staff, the facility failed to test Electrical equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2. Findings include:

a) The facility failed to have a Bio Medical Equipment Preventive Maintenance Program in accordance with NFPA 99 1999 edition chapter 7-6.2.1.1. The Governing Body failed to establish a program and protocols for testing of appliances used in the care, treatment, and entertainment of patients in accordance with Manufacture requirements. Testing intervals shall be in accordance with 7-6.2.1.2.

b) The facility failed to have a program or a mechanism to evaluate the quality of each contracted service and ensures that each contracted service is provided in a safe and effective manner for Fire Alarm Contractor, Fire Suppression Contractor in accordance with ?482.12(e) Standard: Contracted Services Interruptive Guidelines

1) Based on observation and interview with staff, the facility failed to provide with a means suitable for keeping the door closed in its frame ( Latching Hardware) in accordance with 19.3.6.3

a) Latching hardware was removed from doors to room 110 and 111.

1) Based on observation and interview with staff, the facility failed to conduct Fire drills that are held at unexpected times under varying conditions, at least quarterly on each shift in accordance with 19.7.1.2. Findings include:

a) Fire Drills conducted was documented and stated that the area of refuge/ space to exit to was outside of the building. Staff was not trained to horizontally move from one smoke zone to the other. The last option should be to relocate outside.

b) At the bottom of all the Fire Drill Reports, there is a space for follow up. On most all of the Drills, follow up had not taken place and most did not have signatures.

1) Based on observation and interview with staff, the facility failed to provide a fire alarm installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. Findings include:

a) Smoke detectors located in the Dinning Room, Lobby and inside the room just north of the combination fire and smoke wall are located in the airstream of the HVAC Supply Grill, preventing the detector from detecting smoke.

b) Annual Fire Alarm Report was not signed by the Technician or Owner Representative. The report was faxed and the facility was not briefed on the report.

c) Annual report provided for review and used for documentation of the Annual Report does not meet the minimum requirements in accordance with NFPA 72 chapter 7-5.2.2. 1999 EDITION.

1) Based on observation and interview with staff, the facility failed to properly maintained and test the automatic sprinkler system automatic sprinkler system, Standard for the Installation of Sprinkler Systems.

a) The annual test conducted by Fire Troll on February 19, 2014 was faxed back to the facility, the report failed to have signatures of the inspector and the owners representative. The vendor did not explain results of the test with the owner's representative.

1) Based on observation and interview with staff, the facility failed to provide Heating, ventilating, and air conditioning systems that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2

a) 3 exhaust fans on the roof were burnt out and not working. The fourth had a motor that was very hot and turning very slow. Preventive maintenance Program did not include Exhaust Fans.

b) The facility did not have a HVAC commissioning report ( Test and Balance Report for Indoor air quality) that depicted air exchanges in patient rooms and treatment rooms.

1) Based on observation, interview with staff, and review of the Generator Logs provided by the facility, the facility failed to inspected the Generator weekly and exercised it under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1.

a) The Generator Log failed to have the Name Plate Rating/ Size.

b) The Generator log failed to have the % of load documented.

c) The Generator log failed to have an Log Sheet signed by the operator and reviewed by the Governing Body/ Reviewers Signature as required by the Log Sheet and adopted by the facility.

1) Based on observation and interview with staff, the facility failed to test Electrical equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2. Findings include:

a) The facility failed to have a Bio Medical Equipment Preventive Maintenance Program in accordance with NFPA 99 1999 edition chapter 7-6.2.1.1. The Governing Body failed to establish a program and protocols for testing of appliances used in the care, treatment, and entertainment of patients in accordance with Manufacture requirements. Testing intervals shall be in accordance with 7-6.2.1.2.

b) The facility failed to have a program or a mechanism to evaluate the quality of each contracted service and ensures that each contracted service is provided in a safe and effective manner for Fire Alarm Contractor, Fire Suppression Contractor in accordance with ?482.12(e) Standard: Contracted Services Interruptive Guidelines