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Based on a review of the facility records and interview with the staff it was determined that the facility failed to ensure the staff was trained in emergency fire procedures as frequently as required, consisting of at least one fire drill per shift per quarter, and all Laboratory staff members must participate at least annually. A lack of established routine fire drills for the staff could negate their ability to react without panic, to act swiftly, and orderly without adding to an incident or prolonging exposure to an unsuitable environment.

The findings include:

During the record review and staff interviews the facility could not provide documentation that the required quarterly fire drills had been conducted for the Laboratory personnel.

On 12/05/11 at 2:25 p.m. surveyor spoke to the director of the laboratory and received documentation which revealed that the lab did not conduct the required quarterly fire drills.

NFPA 101 2000 edition
NFPA 99 1999 edition: 10-2.1.4.3*

Based on observation Brooksville Regional Hospital failed to provide a properly tested and maintained fire alarm system. The deficient practice would affect all smoke compartments, all patients and staff.

Findings include:

It was observed on 12/06/11 at 10:10 a.m. during the inspection and testing of the fire alarm system, that consisted of multiple components, that the automatic dialer component, when placed in trouble from phone line failure, located in the first floor communication room, did not send a trouble signal to the main fire alarm control panel (FACP). The FACP was located in the first floor communication room. The first floor communication room where the automatic dialer component was located, gave an audible trouble signal. The fire alarm control remote zone indicator located at the PBX station identified all systems were normal when the automatic dialer panel of the system was in trouble. The trouble signal could not be heard at the PBX first floor business office which is a continuously occupied location. The system was not functioning as a single system with all trouble signals located in an area where they were likely to be heard. One panel indicated troubled conditions while the other panel indicated that the system was normal.

Actual NFPA standard: Fire alarm system components shall be permitted to share control equipment or shall be able to operate as stand alone subsystems, but, in any case, they shall be arranged to function as a single system. NFPA 72 section 3-8.1.
Actual NFPA standard: Trouble Signals.
Trouble signals and their restoration to normal shall be indicated within 200 seconds at the locations identified in 1-5.4.6.1 or 1-5.4.6.2. Trouble signals required to indicate at the protected premises shall be indicated by distinctive audible signals. These audible trouble signals shall be distinctive from alarm signals. If an intermittent signal is used, it shall sound at least once every 10 seconds, with a minimum duration of 1/2 second. An audible trouble signal shall be permitted to be common to several supervised circuits. The trouble signal(s) shall be located in an area where it is likely to be heard. NFPA 72 section 1-5.4.6.
Actual NFPA standard: Distinctive Signals. Fire alarms, supervisory signals, and trouble signals shall be distinctively and descriptively annunciated. NFPA 72 section 1-5.4.4.

Based on an observation, staff interview and record review conducted during the survey on 12/06/11 it was determined that the water supply system failed to be completely maintained. This condition could place the lives of the occupants in danger should a fire occur and the fire sprinkler system failed to respond.

Findings include:

The hospital has fire hydrants on their property which has no documentation that they have been flushed or exercised annually.

The director of maintenance was unsure if the local fire department has completed the yearly inspection and testing as required.

This surveyor spoke to a local representative from the local fire department at 8:45 a.m. on 12/06/11 and he was unsure if the fire department has inspected or tested the hydrants located on the property.

NFPA 101 (2000 edition)
NFPA 25

1. Based on a review of the facility records and interview with the staff on 12/05/11 it was determined that the facility failed to ensure that all required testing and inspection and testing of the electrical system was performed. This renders the equipment unreliable.

The findings include:

At 10:50 a.m. on 12/05/11, there was no documentation available at the time of the survey to show that the main and feeder circuit breakers are inspected and exercised annually as required. The engineering staff stated that this testing was not performed.

NFPA 101-2000
NFPA 99 3-4.4.1.2.(a).

2. Based on a review of the records and interview with the staff at 11:35 a.m. it was determined that the facility failed to ensure that all required testing of the essential electrical system was performed in accordance with NFPA 99. A lack of testing renders the equipment unreliable and an undetected issue in the system could cause an interruption of power during surgery without warning.

The findings include:

There was no documentation during the 12/05/11 survey to that the Line Isolation Monitor test instrument are tested annually as required. The Director of Maintenance confirmed at 11:35 a.m. that this testing was not done, and there was no program in place to ensure compliance.

NFPA 101 (2000 edition)
NFPA 99 (1999 edition) 3.3.3.4.2

Based on a review of the facility records and interview with the staff it was determined that the facility failed to ensure the staff was trained in emergency fire procedures as frequently as required, consisting of at least one fire drill per shift per quarter, and all Laboratory staff members must participate at least annually. A lack of established routine fire drills for the staff could negate their ability to react without panic, to act swiftly, and orderly without adding to an incident or prolonging exposure to an unsuitable environment.

The findings include:

During the record review and staff interviews the facility could not provide documentation that the required quarterly fire drills had been conducted for the Laboratory personnel.

On 12/05/11 at 2:25 p.m. surveyor spoke to the director of the laboratory and received documentation which revealed that the lab did not conduct the required quarterly fire drills.

NFPA 101 2000 edition
NFPA 99 1999 edition: 10-2.1.4.3*

Based on observation Brooksville Regional Hospital failed to provide a properly tested and maintained fire alarm system. The deficient practice would affect all smoke compartments, all patients and staff.

Findings include:

It was observed on 12/06/11 at 10:10 a.m. during the inspection and testing of the fire alarm system, that consisted of multiple components, that the automatic dialer component, when placed in trouble from phone line failure, located in the first floor communication room, did not send a trouble signal to the main fire alarm control panel (FACP). The FACP was located in the first floor communication room. The first floor communication room where the automatic dialer component was located, gave an audible trouble signal. The fire alarm control remote zone indicator located at the PBX station identified all systems were normal when the automatic dialer panel of the system was in trouble. The trouble signal could not be heard at the PBX first floor business office which is a continuously occupied location. The system was not functioning as a single system with all trouble signals located in an area where they were likely to be heard. One panel indicated troubled conditions while the other panel indicated that the system was normal.

Actual NFPA standard: Fire alarm system components shall be permitted to share control equipment or shall be able to operate as stand alone subsystems, but, in any case, they shall be arranged to function as a single system. NFPA 72 section 3-8.1.
Actual NFPA standard: Trouble Signals.
Trouble signals and their restoration to normal shall be indicated within 200 seconds at the locations identified in 1-5.4.6.1 or 1-5.4.6.2. Trouble signals required to indicate at the protected premises shall be indicated by distinctive audible signals. These audible trouble signals shall be distinctive from alarm signals. If an intermittent signal is used, it shall sound at least once every 10 seconds, with a minimum duration of 1/2 second. An audible trouble signal shall be permitted to be common to several supervised circuits. The trouble signal(s) shall be located in an area where it is likely to be heard. NFPA 72 section 1-5.4.6.
Actual NFPA standard: Distinctive Signals. Fire alarms, supervisory signals, and trouble signals shall be distinctively and descriptively annunciated. NFPA 72 section 1-5.4.4.

Based on an observation, staff interview and record review conducted during the survey on 12/06/11 it was determined that the water supply system failed to be completely maintained. This condition could place the lives of the occupants in danger should a fire occur and the fire sprinkler system failed to respond.

Findings include:

The hospital has fire hydrants on their property which has no documentation that they have been flushed or exercised annually.

The director of maintenance was unsure if the local fire department has completed the yearly inspection and testing as required.

This surveyor spoke to a local representative from the local fire department at 8:45 a.m. on 12/06/11 and he was unsure if the fire department has inspected or tested the hydrants located on the property.

NFPA 101 (2000 edition)
NFPA 25

1. Based on a review of the facility records and interview with the staff on 12/05/11 it was determined that the facility failed to ensure that all required testing and inspection and testing of the electrical system was performed. This renders the equipment unreliable.

The findings include:

At 10:50 a.m. on 12/05/11, there was no documentation available at the time of the survey to show that the main and feeder circuit breakers are inspected and exercised annually as required. The engineering staff stated that this testing was not performed.

NFPA 101-2000
NFPA 99 3-4.4.1.2.(a).

2. Based on a review of the records and interview with the staff at 11:35 a.m. it was determined that the facility failed to ensure that all required testing of the essential electrical system was performed in accordance with NFPA 99. A lack of testing renders the equipment unreliable and an undetected issue in the system could cause an interruption of power during surgery without warning.

The findings include:

There was no documentation during the 12/05/11 survey to that the Line Isolation Monitor test instrument are tested annually as required. The Director of Maintenance confirmed at 11:35 a.m. that this testing was not done, and there was no program in place to ensure compliance.

NFPA 101 (2000 edition)
NFPA 99 (1999 edition) 3.3.3.4.2