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Based on document review and interview, the facility failed to test the fire alarm system monthly to confirm the signal with the central monitoring Station. This was evidenced by no documentation of monthly testing. This had the potential for alarm transmission failure, to the monitoring station, in the event of a fire. This affected the entire facility.

NFPA 72, National Fire Alarm Code (1999 Edition)
Table 7-3.2, Testing Frequencies, Item 23 - requires the system be tested monthly with the Monitoring/Supervising Station.

Findings:

During document review with the Facility Manager on July 24, 2012, the maintenance and testing records for the fire alarm system were reviewed.

At 11:22 a.m., the facility failed to provide documentation for the monthly testing of the fire alarm system with confirmation the central station received all signals.

At 11:24 a.m., during an interview, the Facility Manager stated the only documentation of testing the fire alarm system was for the fire alarm system annual certification and the quarterly sprinkler system testing by the vendor. The Facility Manager stated there was no documentation for monthly fire alarm testing, to confirm alarm signals with the monitoring station.

Based on document review and interview, the facility failed to maintain 3 of 3 emergency generators in accordance with NFPA 99. This was evidenced by incomplete documentation for weekly visual inspections of all the emergency generator components. This could result in a failure of the emergency generator in the event of power outage, and could result in potential harm to patients.

NFPA 99, Health Care Facilities, 1999 Edition 3-4.4.2 Recordkeeping. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

Findings:

During document review and interview with the Facility Manager, on July 24, 2012, the emergency generator logs were reviewed.

At 11:38 a.m., the weekly visual inspection logs for 3 of 3 facility emergency generators were incomplete. The logs provided for weekly visual inspections were dated from June 22, 2012 to July 2012.

At 11:44 a.m., during an interview, the Facility Manager stated he did not know weekly visual inspections were required to be documented and was just informed during a June survey.