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1) Based on observation, review of the annual fire alarm systems inspection and interview with staff, the facility failed to test, and maintain fire alarm system required for life safety, in accordance with NFPA 70 National Electrical Code and NFPA 72. Findings include:

a) The annual fire alarm systms inspection report, conducted in June of 2014, did not document the Fire Dampers as being tested. These dampers are connected to the fire alarm system. All system components are to be tested annually in accordance with NFPA 72 1999 edition, CHAPTER 7 Maintenance & Testing.

b) The Fire Dampers were not spelled out on the Directory of points. The control zam was spelled out, however it did not identify the components it controlled such as the Fire Dampers or how many fire dampers. This was verified by the Director of Engineering on December 16, 2014, at 2:30 PM.

1) The governing body failed to take actions through the hospital ' s QAPI program to assess the services furnished under contract for the facility, which identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities are implemented. See §482.12(e) Standard: Contracted Services QAPI.

a) Based on interview with the Director of Engineering on December 16, 2014, at 2 PM the Director nor anyone else from the facility could verify that the exterminator was using chemicals that were friendly to the environment of care. There was no documentation available or furnished that shows oversight/monitoring of the contracted service being provided.

1 Based on observation, review of the Emergency Generator Log and interview with Director of Engineering on December 16, 2014, at 1:45 PM, the facility failed to inspect weekly and exercise Generators under load for 30 minutes per month, in accordance with NFPA 99.3.4.4.1.Findings include:

a) The emergency generator log that is used to verify that the Generator is exercised monthly under load did not document the percentage of the name plate rating when being exercised for the monthly test. This was verified by the Director of engineering.

1) Based on observation, review of the annual fire alarm systems inspection and interview with staff, the facility failed to test, and maintain fire alarm system required for life safety, in accordance with NFPA 70 National Electrical Code and NFPA 72. Findings include:

a) The annual fire alarm systms inspection report, conducted in June of 2014, did not document the Fire Dampers as being tested. These dampers are connected to the fire alarm system. All system components are to be tested annually in accordance with NFPA 72 1999 edition, CHAPTER 7 Maintenance & Testing.

b) The Fire Dampers were not spelled out on the Directory of points. The control zam was spelled out, however it did not identify the components it controlled such as the Fire Dampers or how many fire dampers. This was verified by the Director of Engineering on December 16, 2014, at 2:30 PM.

1) The governing body failed to take actions through the hospital ' s QAPI program to assess the services furnished under contract for the facility, which identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities are implemented. See §482.12(e) Standard: Contracted Services QAPI.

a) Based on interview with the Director of Engineering on December 16, 2014, at 2 PM the Director nor anyone else from the facility could verify that the exterminator was using chemicals that were friendly to the environment of care. There was no documentation available or furnished that shows oversight/monitoring of the contracted service being provided.

1 Based on observation, review of the Emergency Generator Log and interview with Director of Engineering on December 16, 2014, at 1:45 PM, the facility failed to inspect weekly and exercise Generators under load for 30 minutes per month, in accordance with NFPA 99.3.4.4.1.Findings include:

a) The emergency generator log that is used to verify that the Generator is exercised monthly under load did not document the percentage of the name plate rating when being exercised for the monthly test. This was verified by the Director of engineering.