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NFPA 101 (2000) LIFE SAFETY CODE SURVEY REGULATION - Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9 PM and 6 AM a coded announcement may be used instead of audible alarms. 19.7.1.2

This STANDARD is not met as evidenced by:
Based upon a review of available records, it was determined the facility failed to conduct one or more quarterly fire drills during the previous year, in accordance with NFPA 101 (2000) Chapter 19, Section 19.7.1.2.. During a fire emergency, this deficient practice could adversely affect all patients, staff and visitors throughout the facility.

FINDINGS INCLUDE:

On 8/21/12 between 8:00 AM and 1:30 PM, during an interview with the chief building engineer, no documentation could be provided verifying that fire drills were conducted during any quarter of the previous year.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY REGULATION - Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9 PM and 6 AM a coded announcement may be used instead of audible alarms. 19.7.1.2

This STANDARD is not met as evidenced by:
Based upon a review of available records, it was determined the facility had failed to conduct one or more quarterly fire drills during the previous year, in accordance with NFPA 101 (2000) Chapter 19, Section 19.7.1.2. In a fire emergency, this deficient practice could adversely affect all patients, staff and visitors throughout the facility.

FINDINGS INCLUDE:

On 8/21/12 between 8:00 AM and 1:30 PM, while reviewing fire drill reports provided by facility staff, it was confirmed that fire drills were not conducted during the 3rd Quarter of 2011 and the 2nd Quarter of 2012.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY REGULATION - A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with NFPA 70 National Electrical Code (1999 edition) and NFPA 72 National Fire Alarm Code (1999 edition). The system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70 (99) and NFPA 72 (99) and NFPA 101 Life Safety Code (2000 edition), Chapter 9, Section 9.6.1.4.

This STANDARD is not met as evidenced by:
Based upon a staff interview and review of available records, the required annual inspection and testing of the building fire alarm system had not been conducted within the previous year. In a fire emergency, this deficient practice could adversely affect 48 of 48 patients, staff and visitors.

FINDINGS INCLUDE:

On 8/20/12 between 11:30 AM and 5:30 PM, during a review of available documentation provided by the facility's chief building engineer, it was confirmed the required annual inspection/testing of the building fire alarm system was not performed within the previous year. Specifically, the most recent inspection of record was completed by a contract vendor and occurred on 11/18/2010. This deficient practice was not in conformance with the requirements at NFPA 72 (99) Chapter 7, Section 7-3.2.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - There is an automatic sprinkler system, installed in accordance with NFPA 13 (1999), Standard for the Installation of Sprinkler Systems, with approved components, devices, and equipment, to provide complete coverage of all portions of the facility. The system is maintained in accordance with NFPA 25 (1998), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. There is a reliable, adequate water supply for the system. The system is equipped with water flow and tamper switches which are connected to the fire alarm system, in accordance with NFPA 101 (2000), Chapter 18, Section 18.3.5. and Chapter 9, Section 9.7.

This STANDARD is not met as evidenced by:
Based upon observation, a hydraulic fluid actuated elevator was not equipped with automatic fire sprinklering in the pit below the car, nor in the elevator machine room.

FINDINGS INCLUDE:

On 8/20/12 between 11:30 AM and 5:30 PM, the following observations were made:
A). The elevator machine room serving the 2006 oncology link elevator was not equipped with automatic fire sprinklers;
B). The pit (bottom of hoistway) of the 2006 oncology link elevator was not equipped with automatic fire sprinklers.

These findings were confirmed with the chief building engineer at the times of discovery.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY REGULATION - Generators must be inspected weekly and exercised under load at not less than 30% of the EPS nameplate rating, for 30 minutes per month and shall be in accordance with NFPA 99 (1999 edition) and NFPA 110 (1999 edition).

This STANDARD is not met as evidenced by:
Based upon a staff interview and review of available records, the facility was unable to achieve a 30% loading of the emergency generator monthly, during the previous year. In a fire or other emergency, this deficient practice could adversely affect 48 of 48 patients, staff and visitors.

FINDINGS INCLUDE:

On 8/20/12 between 11:30 AM and 5:30 PM, during a review of available records provided by the facility's chief building engineer, it was confirmed the facility had exercised the emergency generator (genset) for not less than 30 minutes on a monthly basis during the previous year. However, in reviewing the facility's Emergency Generator Monthly Test Log, it was confirmed the facility did not achieve the required 30% loading of the genset during any month of the previous year. This deficient practice was not in conformance with NFPA 110 (1999), Chapter 6, Section 6-4.2 and NFPA 99 (1999), Chapter 3, Section 3-4.4.1.1.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY REGULATION - Generators must be inspected weekly and exercised under load at not less than 30% of the EPS nameplate rating, for 30 minutes per month and shall be in accordance with NFPA 99 (1999 edition) and NFPA 110 (1999 edition).

This STANDARD is not met as evidenced by:
Based upon a staff interview and review of available records, the facility was unable to achieve a 30% loading of the emergency generator monthly, during the previous year. In a fire or other emergency, this deficient practice could adversely affect 48 of 48 patients, staff and visitors.

FINDINGS INCLUDE:

On 8/20/12 between 11:30 AM and 5:30 PM, during a review of the facility's Emergency Generator Monthly Test Log, it was confirmed the facility did not achieve the required 30% loading of the genset during any month of the previous year. This deficient practice was not in conformance with NFPA 110 (1999), Chapter 6, Section 6-4.2 and NFPA 99 (1999), Chapter 3, Section 3-4.4.1.1.

This finding was confirmed with the chief building engineer.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY REGULATION - Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9 PM and 6 AM a coded announcement may be used instead of audible alarms. 19.7.1.2

This STANDARD is not met as evidenced by:
Based upon a review of available records, it was determined the facility failed to conduct one or more quarterly fire drills during the previous year, in accordance with NFPA 101 (2000) Chapter 19, Section 19.7.1.2.. During a fire emergency, this deficient practice could adversely affect all patients, staff and visitors throughout the facility.

FINDINGS INCLUDE:

On 8/21/12 between 8:00 AM and 1:30 PM, during an interview with the chief building engineer, no documentation could be provided verifying that fire drills were conducted during any quarter of the previous year.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY REGULATION - Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9 PM and 6 AM a coded announcement may be used instead of audible alarms. 19.7.1.2

This STANDARD is not met as evidenced by:
Based upon a review of available records, it was determined the facility had failed to conduct one or more quarterly fire drills during the previous year, in accordance with NFPA 101 (2000) Chapter 19, Section 19.7.1.2. In a fire emergency, this deficient practice could adversely affect all patients, staff and visitors throughout the facility.

FINDINGS INCLUDE:

On 8/21/12 between 8:00 AM and 1:30 PM, while reviewing fire drill reports provided by facility staff, it was confirmed that fire drills were not conducted during the 3rd Quarter of 2011 and the 2nd Quarter of 2012.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY REGULATION - A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with NFPA 70 National Electrical Code (1999 edition) and NFPA 72 National Fire Alarm Code (1999 edition). The system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70 (99) and NFPA 72 (99) and NFPA 101 Life Safety Code (2000 edition), Chapter 9, Section 9.6.1.4.

This STANDARD is not met as evidenced by:
Based upon a staff interview and review of available records, the required annual inspection and testing of the building fire alarm system had not been conducted within the previous year. In a fire emergency, this deficient practice could adversely affect 48 of 48 patients, staff and visitors.

FINDINGS INCLUDE:

On 8/20/12 between 11:30 AM and 5:30 PM, during a review of available documentation provided by the facility's chief building engineer, it was confirmed the required annual inspection/testing of the building fire alarm system was not performed within the previous year. Specifically, the most recent inspection of record was completed by a contract vendor and occurred on 11/18/2010. This deficient practice was not in conformance with the requirements at NFPA 72 (99) Chapter 7, Section 7-3.2.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - There is an automatic sprinkler system, installed in accordance with NFPA 13 (1999), Standard for the Installation of Sprinkler Systems, with approved components, devices, and equipment, to provide complete coverage of all portions of the facility. The system is maintained in accordance with NFPA 25 (1998), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. There is a reliable, adequate water supply for the system. The system is equipped with water flow and tamper switches which are connected to the fire alarm system, in accordance with NFPA 101 (2000), Chapter 18, Section 18.3.5. and Chapter 9, Section 9.7.

This STANDARD is not met as evidenced by:
Based upon observation, a hydraulic fluid actuated elevator was not equipped with automatic fire sprinklering in the pit below the car, nor in the elevator machine room.

FINDINGS INCLUDE:

On 8/20/12 between 11:30 AM and 5:30 PM, the following observations were made:
A). The elevator machine room serving the 2006 oncology link elevator was not equipped with automatic fire sprinklers;
B). The pit (bottom of hoistway) of the 2006 oncology link elevator was not equipped with automatic fire sprinklers.

These findings were confirmed with the chief building engineer at the times of discovery.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY REGULATION - Generators must be inspected weekly and exercised under load at not less than 30% of the EPS nameplate rating, for 30 minutes per month and shall be in accordance with NFPA 99 (1999 edition) and NFPA 110 (1999 edition).

This STANDARD is not met as evidenced by:
Based upon a staff interview and review of available records, the facility was unable to achieve a 30% loading of the emergency generator monthly, during the previous year. In a fire or other emergency, this deficient practice could adversely affect 48 of 48 patients, staff and visitors.

FINDINGS INCLUDE:

On 8/20/12 between 11:30 AM and 5:30 PM, during a review of available records provided by the facility's chief building engineer, it was confirmed the facility had exercised the emergency generator (genset) for not less than 30 minutes on a monthly basis during the previous year. However, in reviewing the facility's Emergency Generator Monthly Test Log, it was confirmed the facility did not achieve the required 30% loading of the genset during any month of the previous year. This deficient practice was not in conformance with NFPA 110 (1999), Chapter 6, Section 6-4.2 and NFPA 99 (1999), Chapter 3, Section 3-4.4.1.1.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY REGULATION - Generators must be inspected weekly and exercised under load at not less than 30% of the EPS nameplate rating, for 30 minutes per month and shall be in accordance with NFPA 99 (1999 edition) and NFPA 110 (1999 edition).

This STANDARD is not met as evidenced by:
Based upon a staff interview and review of available records, the facility was unable to achieve a 30% loading of the emergency generator monthly, during the previous year. In a fire or other emergency, this deficient practice could adversely affect 48 of 48 patients, staff and visitors.

FINDINGS INCLUDE:

On 8/20/12 between 11:30 AM and 5:30 PM, during a review of the facility's Emergency Generator Monthly Test Log, it was confirmed the facility did not achieve the required 30% loading of the genset during any month of the previous year. This deficient practice was not in conformance with NFPA 110 (1999), Chapter 6, Section 6-4.2 and NFPA 99 (1999), Chapter 3, Section 3-4.4.1.1.

This finding was confirmed with the chief building engineer.