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SANFORD BEHAVIORAL HEALTH CENTER
Sprinkler System - Maintenance and Testing
Tag No.: K0353
Based on observation and staff interview, the facility failed to maintain the sprinkler system in accordance with the 2012 Life Safety Code (NFPA 101) section 9.7.1.1 and NFPA 25 section 5.3.2 & 14.2.1. The standard for testing and maintenance of sprinkler systems. This deficient condition could cause the sprinkler system not to function properly and allow for the spread of fire. This could affect all of the 16 patients and an undetermined amount of staff and visitors.
Findings include:
On the facility tour between 10:00 am to 3:00 pm on 12/10/2018 observations revealed the sprinkler head in storage room 2NW300A was covered in taping compound.
Documentation review revealed there was no record of calibration of the sprinkler gauges or the internal pipe obstruction inspection in the last five years.
This deficient condition was confirmed by the Director of Facilities/Plant Operations Manager.
Fire Drills
Tag No.: K0712
Based on record review and staff interview the facility failed to conduct fire drills as required by the Life Safety Code (NFPA 101) 2012 edition, section 19.7.1.4 to 19.7.1.7. This deficient practice could reduce the ability of staff to conduct a safe and timely response to a fire emergency, which would affect all patients and an undetermined amount of staff and visitors.
Findings include:
On the facility tour between 10:00 am to 3:00 pm on 12/10/2018 Documentation review revealed the fire drills were not conducted;
1. Separate from the other building occupancies.
2. Under varied conditions.
3. At least one hour apart from previous drills.
4. With participant signatures.
This deficient condition was confirmed by the Director of Facilities/Plant Operations Manager.
Electrical Systems - Essential Electric Syste
Tag No.: K0918
Based on observations and staff interview the facility failed to provide emergency features in accordance with the 2012 edition of the Life Safety Code (NFPA 101) section 9.1.3.1 and the 2010 edition of NFPA 110 the Standard for Emergency and Standby Power Systems. This deficient practice could affect the safety of an undetermined amount of staff if the generator failed to shut down during an emergency.
Findings include:
On the facility tour between 10:00 am to 3:00 pm on 12/10/2018 observations revealed the generator did not have a emergency shut off located outside of the enclosure.
This deficient condition was confirmed by the Director of Facilities/Plant Operations Manager.