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Observation on 1/12/2011 between 8:10 am and 10:30 am revealed the requirement of 1999 NPFA 72: 1-5.2.5.2 was not met.

The Standard: Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

Findings: The Fire Alarm Control Panel (FACP) circuit (panel F, circuit 11) and FACP were not cross referenced. FACP circuit was not identified with Red marking in the panel. The FACP panel did not indicate which panel and circuit powered it.

Observation on 1/12/2011 between 8:10 am and 10:30 am revealed the requirement of 1999 NPFA 10: 6-2.1 was not met.

The Standard: Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30 day intervals.

Findings: The last annual inspection was performed in July of 2010. The tags on the extinguishers do not indicate monthly inspections.

Observation and interview on 1/12/2011 between 8:10 am and 10:30 am revealed the requirement of 1999 NFPA 99, 4-3.2.2.8 (a) and 4-3.1.2.2 (b)2 was not met.

The Standard: To ensure continuous responsible observation of the vacuum system and med gas, the master alarm signal panels shall be located in two separate warning locations. One shall be in the office or principal working area of the person responsible for the maintenance of the system and at a continuously staffed location.
Findings: No med gas or vacuum alarms were located in or near the maintenance office. The only alarm in the facility was located in the Nurse Station.

A. Interview and review of records on 1/12/2011 between 8:10 am and 10:30 am revealed the requirement of 1999 NPFA 72: 7-3.2.1 was not met.
The Standard: Detectors sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After 2 years of sensitivity testing, the smoke detector fall in the prescribed sensitivity range, testing can be extended up to 5 years.

Findings: Records indicating sensitivity testing including sensitivity reading was found for years 2001 and 2003. No other records of this type were found. It was unclear as to whether this testing has been done since 2003. The documentation did not detailed enough to make a determination.
The fire alarm inspection records for 2/10/2010 indicated 35 smoke alarms, with no indication of duct detectors. Prior records from 2005 indicated 38 detectors, including duct detectors.

B. Observation on 1/12/2011 between 8:10 am and 10:30 am revealed the requirement of 1999 NPFA 99: 11-5.3.9 was not met.

The Standard: Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.
Findings: A copy of the policy was found but has not been implemented. No records of the drills were found.

A. Observation, interview and review of records on 1/12/2011 between 8:10 am and 10:30 am revealed the requirement of 1999 NPFA 110: 8-4.2 was not met.

The Standard: A 2 hour load test for the generator must be conducted annually.

Findings: Reports were found dated 1/12/09 and 1/10/11, indicating a time frame exceeding the requirement.

B. Observation, interview and review of records on 1/12/2011 between 8:10 am and 10:30 am revealed the requirement of 1999 NPFA 110: 8-4.8 was not met.

The Standard: A 4 hour load test for the generator must be conducted between 36 and 48 month intervals.

Findings: No documentation for this test was found and staff indicated they were not aware of the requirement.

Observation on 1/12/2011 between 8:10 am and 10:30 am revealed the requirement of 1999 NPFA 72: 1-5.2.5.2 was not met.

The Standard: Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

Findings: The Fire Alarm Control Panel (FACP) circuit (panel F, circuit 11) and FACP were not cross referenced. FACP circuit was not identified with Red marking in the panel. The FACP panel did not indicate which panel and circuit powered it.

Observation on 1/12/2011 between 8:10 am and 10:30 am revealed the requirement of 1999 NPFA 10: 6-2.1 was not met.

The Standard: Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30 day intervals.

Findings: The last annual inspection was performed in July of 2010. The tags on the extinguishers do not indicate monthly inspections.

Observation and interview on 1/12/2011 between 8:10 am and 10:30 am revealed the requirement of 1999 NFPA 99, 4-3.2.2.8 (a) and 4-3.1.2.2 (b)2 was not met.

The Standard: To ensure continuous responsible observation of the vacuum system and med gas, the master alarm signal panels shall be located in two separate warning locations. One shall be in the office or principal working area of the person responsible for the maintenance of the system and at a continuously staffed location.
Findings: No med gas or vacuum alarms were located in or near the maintenance office. The only alarm in the facility was located in the Nurse Station.

A. Interview and review of records on 1/12/2011 between 8:10 am and 10:30 am revealed the requirement of 1999 NPFA 72: 7-3.2.1 was not met.
The Standard: Detectors sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After 2 years of sensitivity testing, the smoke detector fall in the prescribed sensitivity range, testing can be extended up to 5 years.

Findings: Records indicating sensitivity testing including sensitivity reading was found for years 2001 and 2003. No other records of this type were found. It was unclear as to whether this testing has been done since 2003. The documentation did not detailed enough to make a determination.
The fire alarm inspection records for 2/10/2010 indicated 35 smoke alarms, with no indication of duct detectors. Prior records from 2005 indicated 38 detectors, including duct detectors.

B. Observation on 1/12/2011 between 8:10 am and 10:30 am revealed the requirement of 1999 NPFA 99: 11-5.3.9 was not met.

The Standard: Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.
Findings: A copy of the policy was found but has not been implemented. No records of the drills were found.

A. Observation, interview and review of records on 1/12/2011 between 8:10 am and 10:30 am revealed the requirement of 1999 NPFA 110: 8-4.2 was not met.

The Standard: A 2 hour load test for the generator must be conducted annually.

Findings: Reports were found dated 1/12/09 and 1/10/11, indicating a time frame exceeding the requirement.

B. Observation, interview and review of records on 1/12/2011 between 8:10 am and 10:30 am revealed the requirement of 1999 NPFA 110: 8-4.8 was not met.

The Standard: A 4 hour load test for the generator must be conducted between 36 and 48 month intervals.

Findings: No documentation for this test was found and staff indicated they were not aware of the requirement.