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Based on review of available reports and records, it was determined that the facility has failed to properly conduct fire drills in accordance with NFPA 101 (00), Chapter 19, Section 19.7.1.2.. This deficient practice could affect how staff react in a fire emergency and could adversely affect the safety of all patients, staff and visitors.

FINDINGS INCLUDE:
On facility tour between 09:00 AM and 12:00 PM on 07/01/2010, during a review of fire drill reports provided by the facility Maintenance Engineer (RS), it was noted that the facility did not vary the times as required for fire drills during the Evening Shift in the last 12 months. Evening shift drills 4 of 6 drills were conducted during the 4:00 PM hour.
This deficiency was verified by the facility Maintenance Engineer (RS),

Smoke detectors are required in sleeping rooms according to LSC(00) Sections 6.1.14 and 26.3.3.5.

Automatic smoke detection was not installed as required in staff on-call sleeping rooms. This deficient practice could affect the safety of any staff sleeping in these rooms.

Findings include:
On facility tour between 09:00 AM and 12:00 PM on 07/01/2010, it was observed that the staff on-call sleeping rooms did not have single-station smoke detectors. Rooms include:
A) 2 Staff ON-Call sleeping rooms.
B) Doctors ON-Call sleeping room.

The facility failed to maintain the emergency generator in accordance with the requirements of NFPA 110 - 1999 edition and NFPA 99 - 1999 edition, section 3-4.1.1.2. This deficient practice could affect the safety of all patients, staff and visitors.

Findings include:

On facility tour between 08:30 AM and 12:00 PM on 07/01/2010, it was revealed during review of available emergency generator records and interview with facility Maintenance Engineer (RS), that records showed the emergency generator has been tested under load on a monthly basis. However, weekly inspections have not been conducted in the last 6 months.






*TEAM COMPOSITION*
Tom Linhoff, Life Safety Code Spc.

Based on review of available reports and records, it was determined that the facility has failed to properly conduct fire drills in accordance with NFPA 101 (00), Chapter 19, Section 19.7.1.2.. This deficient practice could affect how staff react in a fire emergency and could adversely affect the safety of all patients, staff and visitors.

FINDINGS INCLUDE:
On facility tour between 09:00 AM and 12:00 PM on 07/01/2010, during a review of fire drill reports provided by the facility Maintenance Engineer (RS), it was noted that the facility did not vary the times as required for fire drills during the Evening Shift in the last 12 months. Evening shift drills 4 of 6 drills were conducted during the 4:00 PM hour.
This deficiency was verified by the facility Maintenance Engineer (RS),

Smoke detectors are required in sleeping rooms according to LSC(00) Sections 6.1.14 and 26.3.3.5.

Automatic smoke detection was not installed as required in staff on-call sleeping rooms. This deficient practice could affect the safety of any staff sleeping in these rooms.

Findings include:
On facility tour between 09:00 AM and 12:00 PM on 07/01/2010, it was observed that the staff on-call sleeping rooms did not have single-station smoke detectors. Rooms include:
A) 2 Staff ON-Call sleeping rooms.
B) Doctors ON-Call sleeping room.

The facility failed to maintain the emergency generator in accordance with the requirements of NFPA 110 - 1999 edition and NFPA 99 - 1999 edition, section 3-4.1.1.2. This deficient practice could affect the safety of all patients, staff and visitors.

Findings include:

On facility tour between 08:30 AM and 12:00 PM on 07/01/2010, it was revealed during review of available emergency generator records and interview with facility Maintenance Engineer (RS), that records showed the emergency generator has been tested under load on a monthly basis. However, weekly inspections have not been conducted in the last 6 months.






*TEAM COMPOSITION*
Tom Linhoff, Life Safety Code Spc.