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Based on observation and interview, the facility failed to ensure 1 of 22 second floor corridor doors and 4 of 32 third floor corridor doors closed and latched into the door frame. This deficient practice could affect 2 patients on the second floor and patients in the medical/surgery area on the third floor.

Findings include:

Based on observations with the Director of Environmental Services 07/10/13 from 12:30 p.m. to 12:50 p.m., the corridor door to the treatment room on the second floor lacked latching hardware and failed to latch into the door frame. The following areas on the third floor lacked latching hardware and failed to latch into the door frame; two storage rooms, one clean linen room and one laundry chute room containing four trash barrels. This was acknowledged by the Director of Environmental Services at the time of observations.

Based on observation and interview, the facility failed to ensure the corridor door to 1 of 1 main laboratory, 1 of 1 medical records office with combustibles measuring over 50 square feet in size, 1 of 1 second floor soiled utility rooms, 1 of 1 infectious waste storage rooms, and 1 of 1 set of double doors entering the laundry latched into the door frame. Due to the various locations of this deficient practice, any number of patients could be affected.

Findings include:

Based on observation with the Director of Environmental Services on 07/10/13 from 11:00 a.m. to 1:05 p.m., the corridor door to the following hazardous areas lacked latching hardware and failed to latch into the door frame:
a. the Main Laboratory
b. the Medical Records office, measuring over 1900 square feet, contained 12 rows of open shelves of medical records and 23 cardboard boxes of medical records
c. the double door set entering the laundry room
d. the third floor infectious waste storage room
e. the second floor soiled utility room
This was confirmed by the Director of Environmental Services at the time of observations.

Based on observation and interview, the facility failed to ensure exit access was arranged so 1 of 22 exits was readily accessible at all times in accordance with LSC Section 7.1. LSC Section 7.1 requires that means of egress for existing buildings shall comply with Chapter 7. LSC Section 7.7.1 requires all exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. In addition to providing the required width to allow all occupants safe access to a public way, such access also needs to meet the requirements with respect to maintaining the means of egress free of obstructions that would prevent its use, such as snow and the need for its removal in some climates or soft ground during heavy periods of rain. This deficient practice could affect all occupants evacuated through main dining room and the activity room exits.

Findings include:

Based on observation with the Director of Environmental Services on 07/10/13 at 11:30 a.m., the west exit sidewalk was connected to the parking lot sidewalk by a limestone path. The limestone pieces were placed several inches apart and had grass growing between the pieces providing an uneven surface. The path measures three feet wide and 45 feet long. Measurements were provided by the Director of Environmental Services at the time of observation.

Based on observation and interview, the facility failed to ensure a continuously illuminated exit sign, where the exit or way to reach the exit was not apparent, was immediately visible for 2 of 2 ways to the exit from the Radiology waiting room. LSC 7.10.1.4 requires access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not apparent to the occupants. This deficient practice could affect any patient or visitor in the Radiology waiting room in the event of an emergency.

Findings include:

Based on an observation with the Director of Environmental Services on 07/11/13 at 11:27 a.m., there were no illuminated exit signs from the Radiology waiting room. After the Director of Environmental Services walked the path of egress from the Radiology waiting room he acknowledged the area lacked exit signs.

Based on observation and interview, the facility failed to ensure 1 of 2 fire alarm panels located in an area that were not continuously occupied was provided with automatic smoke detection to ensure notification of a fire at that location before it is incapacitated by fire. NFPA 72 at 1-5.6 requires an automatic smoke detector be provided at the location of each fire alarm control unit which is not located in an area continuously occupied to provide notification of a fire in that location. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Director of Environmental Services on 07/10/13 at 10:40 a.m., the main fire alarm panel located at the main entrance was not electrically supervised by a smoke detector or in an area continuously occupied. This was acknowledged by the Director of Environmental Services at the time of observation.

Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was provided for 2 of 2 elevator equipment rooms in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide complete coverage for all portions of the building. NFPA 13, 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be ordinary or intermediate temperature rating. Exception: Sprinklers shall not be required where all of the following conditions are met: (a) The room is dedicated to electrical equipment only. (b) Only dry-type electrical equipment is used. (c) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations. (d) No combustible storage is permitted to be stored in the room. This deficient practice could affect patients near the elevator equipment rooms.

Findings include:

Based on an observation and interview with the Director of Environmental Services on 07/10/13 at 2:10 p.m., it was acknowledged both elevator equipment rooms lacked sprinkler coverage.

Based on observation and interview, the facility failed to ensure complete automatic sprinkler system was provided for 1 of 1 phone rooms and 1 of 1 previous Radiology department electrical room in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. This deficient practice could affect patients near the main entrance in the event of an emergency.

Findings include:

Based on an observation and interview with the Director of Environmental Services on 07/10/13 from 10:50 a.m. to 11:15 a.m., it was acknowledged the phone room near the main entrance lacked sprinkler coverage as well as the electrical room in the old Radiology department which is no longer in use.

Based on observation and interview, the facility failed to ensure 7 of 7 private fire hydrants were continuously maintained in reliable operating condition, and inspected and tested periodically. NFPA 25, 1998 Edition, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems at Section 4-2.2.4 requires dry barrel hydrants to be inspected annually and after each operation. Hydrants shall be inspected and the necessary corrective action shall be taken. This deficient practice could affect all staff, visitors and residents.

Findings include:

Based on observation and interview with the Director of Environmental Services on 07/11/13 at 11:00 a.m., there were seven private fire hydrant on the facility's property. After placing a call to the local fire department, the Director of Environmental Services stated the seven private fire hydrants had not received an annual inspection.

Based on interview and record review, the facility failed to ensure 12 of 77 dampers were inspected and provided necessary maintenance at least every four years in accordance with NFPA 90A. LSC 9.2.1 requires air conditioning, heating, ventilating ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A, 1999 Edition, 3.4.7, Maintenance, requires at least every 6 years, fusible links shall be removed; all dampers shall be operated to verify they fully close; the latch, if provided, shall be checked, and moving parts shall be lubricated as necessary. This deficient practice affects all occupants.

Findings include:

Based on record review with the Director of Environmental Services on 07/10/13 at 10:30 a.m., the fire damper inspection completed in 10/2008 by facility staff noted the following discrepancies:
a) two dampers missing
b) six dampers need access panels
c) four dampers need parts
Based on an interview with the Maintenance Supervisor at the time of record review, these discrepancies have not been addressed.

Based on interview and record review, the facility failed to ensure 39 of 61 dampers were inspected and provided necessary maintenance at least every four years in accordance with NFPA 90A. LSC 9.2.1 requires air conditioning, heating, ventilating ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A, 1999 Edition, 3.4.7, Maintenance, requires at least every 6 years, fusible links shall be removed; all dampers shall be operated to verify they fully close; the latch, if provided, shall be checked, and moving parts shall be lubricated as necessary. This deficient practice affects all occupants.

Findings include:

Based on record review with the Director of Environmental Services on 07/10/13 at 10:30 a.m., the fire damper inspection completed in 10/2008 by facility staff noted 35 dampers received could not be reached and received only a visual inspection and four dampers were not accessible. Based on an interview with the Maintenance Supervisor at the time of record review, these discrepancies have not been addressed.

1. Based on observation and interview, the facility failed to ensure 1 of 1 waiting room exit signs connected to, or provided with, a battery operated emergency back up power source were tested and would function. LSC 38.2.10 requires means of egress shall have signs in accordance with Section 7.10. LSC 4.5.7 states whenever any device, equipment, system, condition, arrangement, level of protection or any other feature is required for compliance, such device, equipment, system, condition, arrangement, level of protection or other feature shall thereafter be maintained. This deficient practice could affect all occupants in the Butler Clinic including staff, visitors and patients if the facility were required to evacuate in an emergency during a loss of normal power.

Findings include:

Based on observation with the Director of Environmental Services on 07/11/13 at 1:20 p.m., the waiting room exit sign with battery backup failed to illuminate when the battery was tested. At the time of observation, the Director of Environmental Services confirmed the waiting room exit sign did not illuminate when tested.

2. Based on observation and interview, the facility failed to ensure extension cords were not used as a substitute for fixed wiring. LSC 38.5.1 refers to LSC 9.1. LSC 9.1.1 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 1999 Edition. NFPA 70, Article 400-8 requires, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice could affect any staff or patient.

Findings include:

Based on observation and interview with the Director of Environmental Services on 07/11/13 at 1:25 p.m., it was acknowledged a power strip was in use and supplying power to an extension cord which was supplying power to heat tape in the mechanical room.

Based on observation and interview, the facility failed to ensure extension cords were not used as a substitute for fixed wiring. LSC 38.5.1 refers to LSC 9.1. LSC 9.1.1 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 1999 Edition. NFPA 70, Article 400-8 requires, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice could affect any staff or patient.

Findings include:

Based on observation and interview with the Director of Environmental Services on 07/11/13 at 2:55 p.m., it was acknowledged an extension cord was in use and supplying power to a set of decorative lights in exam room #6.

Based on observation and interview, the facility failed to ensure 3 of 3 emergency generators were equipped with a remote manual stop. LSC 7.9.2.3 requires emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 1999 edition, 3-5.5.6 requires Level I installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for shutting down the engine at the engine and from a remote location. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Director of Environmental Services on 07/10/13 from 10:30 a.m. to 2:00 p.m., the facilities did not have a remote manual stop for the three emergency generators. Based on an interview with the Director of Environmental Services at 12:20 p.m., generator A was 200 KW, generator B was 400 KW and generator C was 750 KW therefore all engines were over 100 horsepower.

Based on observation and interview, the facility failed to ensure 1 of 1 sprinklered elevator equipment rooms was provided with an automatic means for disconnecting the main line power supply. NFPA 13, 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be ordinary or intermediate temperature rating. ASME/ANSI A17.1, Safety Code for Elevators and Escalators, permits sprinklers in elevator machine rooms when there is a means for disconnecting the power to the elevator upon or prior to the application of water in elevator machine rooms or hoistways. This shutdown can be accomplished by a detection system with sufficient sensitivity that operates prior to the activation of the sprinklers. As an alternative, the system can be arranged using devices or sprinklers capable of effecting power shutdown immediately upon sprinkler activation, such as a waterflow switch without a time delay. This deficient practice could affect any number of patients and visitors in the event of an emergency.

Findings include:

Based on observation of the elevator equipment room in the mechanical room located on the roof with the Director of Environmental Services on 07/10/13 at 1:00 p.m., the elevator equipment room was provided with sprinkler coverage but lacked a smoke/heat detector. Based on an interview with the Director of Environmental Services at the time of observation, the elevator equipment was provided with a shunt trip but the mechanical room lacked a smoke/heat detector needed to activate the shunt trip in the event of an emergency.

Based on observation and interview, the facility failed to ensure 1 of 22 second floor corridor doors and 4 of 32 third floor corridor doors closed and latched into the door frame. This deficient practice could affect 2 patients on the second floor and patients in the medical/surgery area on the third floor.

Findings include:

Based on observations with the Director of Environmental Services 07/10/13 from 12:30 p.m. to 12:50 p.m., the corridor door to the treatment room on the second floor lacked latching hardware and failed to latch into the door frame. The following areas on the third floor lacked latching hardware and failed to latch into the door frame; two storage rooms, one clean linen room and one laundry chute room containing four trash barrels. This was acknowledged by the Director of Environmental Services at the time of observations.

Based on observation and interview, the facility failed to ensure the corridor door to 1 of 1 main laboratory, 1 of 1 medical records office with combustibles measuring over 50 square feet in size, 1 of 1 second floor soiled utility rooms, 1 of 1 infectious waste storage rooms, and 1 of 1 set of double doors entering the laundry latched into the door frame. Due to the various locations of this deficient practice, any number of patients could be affected.

Findings include:

Based on observation with the Director of Environmental Services on 07/10/13 from 11:00 a.m. to 1:05 p.m., the corridor door to the following hazardous areas lacked latching hardware and failed to latch into the door frame:
a. the Main Laboratory
b. the Medical Records office, measuring over 1900 square feet, contained 12 rows of open shelves of medical records and 23 cardboard boxes of medical records
c. the double door set entering the laundry room
d. the third floor infectious waste storage room
e. the second floor soiled utility room
This was confirmed by the Director of Environmental Services at the time of observations.

Based on observation and interview, the facility failed to ensure exit access was arranged so 1 of 22 exits was readily accessible at all times in accordance with LSC Section 7.1. LSC Section 7.1 requires that means of egress for existing buildings shall comply with Chapter 7. LSC Section 7.7.1 requires all exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. In addition to providing the required width to allow all occupants safe access to a public way, such access also needs to meet the requirements with respect to maintaining the means of egress free of obstructions that would prevent its use, such as snow and the need for its removal in some climates or soft ground during heavy periods of rain. This deficient practice could affect all occupants evacuated through main dining room and the activity room exits.

Findings include:

Based on observation with the Director of Environmental Services on 07/10/13 at 11:30 a.m., the west exit sidewalk was connected to the parking lot sidewalk by a limestone path. The limestone pieces were placed several inches apart and had grass growing between the pieces providing an uneven surface. The path measures three feet wide and 45 feet long. Measurements were provided by the Director of Environmental Services at the time of observation.

Based on observation and interview, the facility failed to ensure a continuously illuminated exit sign, where the exit or way to reach the exit was not apparent, was immediately visible for 2 of 2 ways to the exit from the Radiology waiting room. LSC 7.10.1.4 requires access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not apparent to the occupants. This deficient practice could affect any patient or visitor in the Radiology waiting room in the event of an emergency.

Findings include:

Based on an observation with the Director of Environmental Services on 07/11/13 at 11:27 a.m., there were no illuminated exit signs from the Radiology waiting room. After the Director of Environmental Services walked the path of egress from the Radiology waiting room he acknowledged the area lacked exit signs.

Based on observation and interview, the facility failed to ensure 1 of 2 fire alarm panels located in an area that were not continuously occupied was provided with automatic smoke detection to ensure notification of a fire at that location before it is incapacitated by fire. NFPA 72 at 1-5.6 requires an automatic smoke detector be provided at the location of each fire alarm control unit which is not located in an area continuously occupied to provide notification of a fire in that location. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Director of Environmental Services on 07/10/13 at 10:40 a.m., the main fire alarm panel located at the main entrance was not electrically supervised by a smoke detector or in an area continuously occupied. This was acknowledged by the Director of Environmental Services at the time of observation.

Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was provided for 2 of 2 elevator equipment rooms in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide complete coverage for all portions of the building. NFPA 13, 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be ordinary or intermediate temperature rating. Exception: Sprinklers shall not be required where all of the following conditions are met: (a) The room is dedicated to electrical equipment only. (b) Only dry-type electrical equipment is used. (c) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations. (d) No combustible storage is permitted to be stored in the room. This deficient practice could affect patients near the elevator equipment rooms.

Findings include:

Based on an observation and interview with the Director of Environmental Services on 07/10/13 at 2:10 p.m., it was acknowledged both elevator equipment rooms lacked sprinkler coverage.

Based on observation and interview, the facility failed to ensure complete automatic sprinkler system was provided for 1 of 1 phone rooms and 1 of 1 previous Radiology department electrical room in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. This deficient practice could affect patients near the main entrance in the event of an emergency.

Findings include:

Based on an observation and interview with the Director of Environmental Services on 07/10/13 from 10:50 a.m. to 11:15 a.m., it was acknowledged the phone room near the main entrance lacked sprinkler coverage as well as the electrical room in the old Radiology department which is no longer in use.

Based on observation and interview, the facility failed to ensure 7 of 7 private fire hydrants were continuously maintained in reliable operating condition, and inspected and tested periodically. NFPA 25, 1998 Edition, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems at Section 4-2.2.4 requires dry barrel hydrants to be inspected annually and after each operation. Hydrants shall be inspected and the necessary corrective action shall be taken. This deficient practice could affect all staff, visitors and residents.

Findings include:

Based on observation and interview with the Director of Environmental Services on 07/11/13 at 11:00 a.m., there were seven private fire hydrant on the facility's property. After placing a call to the local fire department, the Director of Environmental Services stated the seven private fire hydrants had not received an annual inspection.

Based on interview and record review, the facility failed to ensure 12 of 77 dampers were inspected and provided necessary maintenance at least every four years in accordance with NFPA 90A. LSC 9.2.1 requires air conditioning, heating, ventilating ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A, 1999 Edition, 3.4.7, Maintenance, requires at least every 6 years, fusible links shall be removed; all dampers shall be operated to verify they fully close; the latch, if provided, shall be checked, and moving parts shall be lubricated as necessary. This deficient practice affects all occupants.

Findings include:

Based on record review with the Director of Environmental Services on 07/10/13 at 10:30 a.m., the fire damper inspection completed in 10/2008 by facility staff noted the following discrepancies:
a) two dampers missing
b) six dampers need access panels
c) four dampers need parts
Based on an interview with the Maintenance Supervisor at the time of record review, these discrepancies have not been addressed.

Based on interview and record review, the facility failed to ensure 39 of 61 dampers were inspected and provided necessary maintenance at least every four years in accordance with NFPA 90A. LSC 9.2.1 requires air conditioning, heating, ventilating ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A, 1999 Edition, 3.4.7, Maintenance, requires at least every 6 years, fusible links shall be removed; all dampers shall be operated to verify they fully close; the latch, if provided, shall be checked, and moving parts shall be lubricated as necessary. This deficient practice affects all occupants.

Findings include:

Based on record review with the Director of Environmental Services on 07/10/13 at 10:30 a.m., the fire damper inspection completed in 10/2008 by facility staff noted 35 dampers received could not be reached and received only a visual inspection and four dampers were not accessible. Based on an interview with the Maintenance Supervisor at the time of record review, these discrepancies have not been addressed.

1. Based on observation and interview, the facility failed to ensure 1 of 1 waiting room exit signs connected to, or provided with, a battery operated emergency back up power source were tested and would function. LSC 38.2.10 requires means of egress shall have signs in accordance with Section 7.10. LSC 4.5.7 states whenever any device, equipment, system, condition, arrangement, level of protection or any other feature is required for compliance, such device, equipment, system, condition, arrangement, level of protection or other feature shall thereafter be maintained. This deficient practice could affect all occupants in the Butler Clinic including staff, visitors and patients if the facility were required to evacuate in an emergency during a loss of normal power.

Findings include:

Based on observation with the Director of Environmental Services on 07/11/13 at 1:20 p.m., the waiting room exit sign with battery backup failed to illuminate when the battery was tested. At the time of observation, the Director of Environmental Services confirmed the waiting room exit sign did not illuminate when tested.

2. Based on observation and interview, the facility failed to ensure extension cords were not used as a substitute for fixed wiring. LSC 38.5.1 refers to LSC 9.1. LSC 9.1.1 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 1999 Edition. NFPA 70, Article 400-8 requires, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice could affect any staff or patient.

Findings include:

Based on observation and interview with the Director of Environmental Services on 07/11/13 at 1:25 p.m., it was acknowledged a power strip was in use and supplying power to an extension cord which was supplying power to heat tape in the mechanical room.

Based on observation and interview, the facility failed to ensure extension cords were not used as a substitute for fixed wiring. LSC 38.5.1 refers to LSC 9.1. LSC 9.1.1 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 1999 Edition. NFPA 70, Article 400-8 requires, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice could affect any staff or patient.

Findings include:

Based on observation and interview with the Director of Environmental Services on 07/11/13 at 2:55 p.m., it was acknowledged an extension cord was in use and supplying power to a set of decorative lights in exam room #6.

Based on observation and interview, the facility failed to ensure 3 of 3 emergency generators were equipped with a remote manual stop. LSC 7.9.2.3 requires emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 1999 edition, 3-5.5.6 requires Level I installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for shutting down the engine at the engine and from a remote location. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Director of Environmental Services on 07/10/13 from 10:30 a.m. to 2:00 p.m., the facilities did not have a remote manual stop for the three emergency generators. Based on an interview with the Director of Environmental Services at 12:20 p.m., generator A was 200 KW, generator B was 400 KW and generator C was 750 KW therefore all engines were over 100 horsepower.

Based on observation and interview, the facility failed to ensure 1 of 1 sprinklered elevator equipment rooms was provided with an automatic means for disconnecting the main line power supply. NFPA 13, 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be ordinary or intermediate temperature rating. ASME/ANSI A17.1, Safety Code for Elevators and Escalators, permits sprinklers in elevator machine rooms when there is a means for disconnecting the power to the elevator upon or prior to the application of water in elevator machine rooms or hoistways. This shutdown can be accomplished by a detection system with sufficient sensitivity that operates prior to the activation of the sprinklers. As an alternative, the system can be arranged using devices or sprinklers capable of effecting power shutdown immediately upon sprinkler activation, such as a waterflow switch without a time delay. This deficient practice could affect any number of patients and visitors in the event of an emergency.

Findings include:

Based on observation of the elevator equipment room in the mechanical room located on the roof with the Director of Environmental Services on 07/10/13 at 1:00 p.m., the elevator equipment room was provided with sprinkler coverage but lacked a smoke/heat detector. Based on an interview with the Director of Environmental Services at the time of observation, the elevator equipment was provided with a shunt trip but the mechanical room lacked a smoke/heat detector needed to activate the shunt trip in the event of an emergency.