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Based on observation and interview, the facility failed to ensure 2 of 2 smoke barriers above the drop ceiling assembly were maintained to provide a one half hour fire resistance rating. LSC 8.3.2 requires smoke barriers shall be continuous from an outside wall to an outside wall. This deficient practice could affect all patient in the facility.

Findings include:

Based on observations with the Maintenance Supervisor on 01/22/16 during a tour of the smoke barriers above the drop ceiling assembly from 12:10 p.m. to 1:25 p.m., the Center Hall smoke barrier wall had a three inch circular area in the center of the smoke barrier wall not fire stopped and the smoke barrier wall between the Mental Health Center and the Main Center had three, one half inch open electrical conduits open on both sides of the smoke barrier wall not firestopped. This was verified by the Maintenance Supervisor at the time of observations and acknowledged by the Director of Inpatient Services at the exit conference on 01/22/16 at 1:50 p.m.

1. Based on record review and interview, the facility failed to ensure 18 photoelectric smoke detectors, 6 audible/visual devices, 1 fire alarm panel, and 8 manual pull station boxes, which were all fire alarm system components were functional tested annually and the results of such testing listed clearly on inspection reports to identify all devices had been tested. LSC 9.6.1.3 indicates provisions of 9.6 cover the basic functions of the fire alarm system, including fire detection system components. LSC 9.6.1.4 refers to NFPA 72, The National Fire Alarm Code. NFPA 72, at 7-3.2 requires testing in accordance with Table 7-3.2, Testing Frequencies. Table 7-3.2.15(f) and (h) requires photoelectric smoke detectors, combined heat/smoke detectors, combined audible/visual devices, separate visual devices, door magnets, and manual pull station fire alarm boxes to be functional tested annually. This deficient practice affects all patients in the facility.

Findings include:

Based on record review on 01/21/16 at 9:35 a.m. with the Director of Inpatient Services, there was no annual fire alarm system inspection records to review to indicate all fire alarm system devices and components had been annually functional tested for the past year. Based on an interview with the director of inpatient services on 01/21/16 at 10:45 a.m., the facility is contracted to have an annual fire alarm system inspection conducted with either Crossman Fire Inc. or Concord Fire Systems Inc. but the annual fire alarm system inspection was not conducted for the year 2015. This was verified by the Director of Inpatient Services at the time of record review and acknowledged at the exit conference on 01/21/16 at 1:50 p.m.

2. Based on record review and interview, the facility failed to ensure 18 of 18 smoke detectors were tested for sensitivity every two years in accordance with the applicable requirements of NFPA 72, National Fire Alarm Code. LSC 9.6.1.3 indicates provisions of 9.6 cover the basic functions of the fire alarm system, including fire detection system components. LSC 9.6.1.4 refers to NFPA 72, The National Fire Alarm Code. NFPA 72, at 7-3.2.1 states, "Detector sensitivity shall be checked within one year after installation and every alternative year thereafter. After the second required calibration test, if sensitivity tests indicate the detectors have remained within their listed and marked sensitivity ranges, the length of time between calibration tests may be extended to a maximum of five years. If the frequency is extended, records of detector caused nuisance alarms shall be maintained. In zones or areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. To ensure each smoke detector is within its listed and marked sensitivity range it shall be tested using the following methods:
(1) Calibrated test method.
(2) Manufacturer's calibrated sensitivity test instrument.
(3) Listed control equipment arranged for the purpose.
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its acceptable sensitivity range.
(5) Other calibrated sensitivity test method acceptable to the authority having jurisdiction.
Detectors found to have sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or replaced.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of aerosol into the detector. NFPA 72, 7-5.2 requires inspection, testing and maintenance reports be provided for the owner or a designated representative. It shall be the responsibility of the owner to maintain these records for the life of the system and to keep them available for examination by the authority having jurisdiction.
This deficient practice affects all patients, staff and all visitors in the facility.

Findings include:

Based on record review on 01/21/16 at 9:50 a.m. with the Director of Inpatient Services, there was no records available for review to indicate the eighteen photoelectric smoke detectors throughout the facility had been tested for sensitivity over the past two years. Based on an interview with the director of inpatient services on 01/21/16 at 10:50 a.m., there is no smoke detector sensitivity test records available for review. This was verified by the Director of Inpatient Services at the time of record review and acknowledged at the exit conference on 01/21/16 at 1:50 p.m.

Based on observation and interview, the facility failed to ensure 2 of 2 smoke barriers above the drop ceiling assembly were maintained to provide a one half hour fire resistance rating. LSC 8.3.2 requires smoke barriers shall be continuous from an outside wall to an outside wall. This deficient practice could affect all patient in the facility.

Findings include:

Based on observations with the Maintenance Supervisor on 01/22/16 during a tour of the smoke barriers above the drop ceiling assembly from 12:10 p.m. to 1:25 p.m., the Center Hall smoke barrier wall had a three inch circular area in the center of the smoke barrier wall not fire stopped and the smoke barrier wall between the Mental Health Center and the Main Center had three, one half inch open electrical conduits open on both sides of the smoke barrier wall not firestopped. This was verified by the Maintenance Supervisor at the time of observations and acknowledged by the Director of Inpatient Services at the exit conference on 01/22/16 at 1:50 p.m.

1. Based on record review and interview, the facility failed to ensure 18 photoelectric smoke detectors, 6 audible/visual devices, 1 fire alarm panel, and 8 manual pull station boxes, which were all fire alarm system components were functional tested annually and the results of such testing listed clearly on inspection reports to identify all devices had been tested. LSC 9.6.1.3 indicates provisions of 9.6 cover the basic functions of the fire alarm system, including fire detection system components. LSC 9.6.1.4 refers to NFPA 72, The National Fire Alarm Code. NFPA 72, at 7-3.2 requires testing in accordance with Table 7-3.2, Testing Frequencies. Table 7-3.2.15(f) and (h) requires photoelectric smoke detectors, combined heat/smoke detectors, combined audible/visual devices, separate visual devices, door magnets, and manual pull station fire alarm boxes to be functional tested annually. This deficient practice affects all patients in the facility.

Findings include:

Based on record review on 01/21/16 at 9:35 a.m. with the Director of Inpatient Services, there was no annual fire alarm system inspection records to review to indicate all fire alarm system devices and components had been annually functional tested for the past year. Based on an interview with the director of inpatient services on 01/21/16 at 10:45 a.m., the facility is contracted to have an annual fire alarm system inspection conducted with either Crossman Fire Inc. or Concord Fire Systems Inc. but the annual fire alarm system inspection was not conducted for the year 2015. This was verified by the Director of Inpatient Services at the time of record review and acknowledged at the exit conference on 01/21/16 at 1:50 p.m.

2. Based on record review and interview, the facility failed to ensure 18 of 18 smoke detectors were tested for sensitivity every two years in accordance with the applicable requirements of NFPA 72, National Fire Alarm Code. LSC 9.6.1.3 indicates provisions of 9.6 cover the basic functions of the fire alarm system, including fire detection system components. LSC 9.6.1.4 refers to NFPA 72, The National Fire Alarm Code. NFPA 72, at 7-3.2.1 states, "Detector sensitivity shall be checked within one year after installation and every alternative year thereafter. After the second required calibration test, if sensitivity tests indicate the detectors have remained within their listed and marked sensitivity ranges, the length of time between calibration tests may be extended to a maximum of five years. If the frequency is extended, records of detector caused nuisance alarms shall be maintained. In zones or areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. To ensure each smoke detector is within its listed and marked sensitivity range it shall be tested using the following methods:
(1) Calibrated test method.
(2) Manufacturer's calibrated sensitivity test instrument.
(3) Listed control equipment arranged for the purpose.
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its acceptable sensitivity range.
(5) Other calibrated sensitivity test method acceptable to the authority having jurisdiction.
Detectors found to have sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or replaced.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of aerosol into the detector. NFPA 72, 7-5.2 requires inspection, testing and maintenance reports be provided for the owner or a designated representative. It shall be the responsibility of the owner to maintain these records for the life of the system and to keep them available for examination by the authority having jurisdiction.
This deficient practice affects all patients, staff and all visitors in the facility.

Findings include:

Based on record review on 01/21/16 at 9:50 a.m. with the Director of Inpatient Services, there was no records available for review to indicate the eighteen photoelectric smoke detectors throughout the facility had been tested for sensitivity over the past two years. Based on an interview with the director of inpatient services on 01/21/16 at 10:50 a.m., there is no smoke detector sensitivity test records available for review. This was verified by the Director of Inpatient Services at the time of record review and acknowledged at the exit conference on 01/21/16 at 1:50 p.m.