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A. Based on record review it was determined that the facility failed to document that fire drills are being conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintainance engineers, and adminsitrative staff) with the signals and emergency action as required. Fire drills are not being conducted, at least quarterly on each shift.

The finding is:

1. On the afternoon of 06/26/12 during a review of the fire drill records with the facility representatives the surveyor found the only available quarterly fire drills were for March, 2012 and June, 2012. There were no available written drills for the previous two quarters in order to obtain a 12 month account of Fire Drills. The surveyor was provided a spread sheet showing previous listed drills however no further documentation was provided. It was determined that quarterly fire drills were not provided throughout the annual cycle to comply with section 19.7.1.2.

A. Corrected 03/06/13.

B. Based on document review and random observation during the test of the fire alarm system on the afternoon of 06/26/12, not all areas of the building fire alarm system are installed in accordance with NFPA-72 (1999). This could effect egress for building occupants within four smoke compartments if the fire alarm system does not operate properly during a fire emergency.
Findings include:

1. During fire drill document review the remarks section of the drill conducted on 6/21/12 in the Adolescent Unit, read "alarm very loud, hard to hear location of code, need to know where we go?"
During the test of the fire alarm system the audible alarm in each of the three "bump out" additions to the patient wings was confirmed to be loud, persons are unable to hear the location of the code, fire origin and therefore the direction of egress. The current condition does not comply with NFPA 72, 1999, 4-3.2.1 and 4-3.1.5 is not complied with concerning the requirement for " messages with voice intelligibility".

NEW ITEM 03/06/13: During an interview held in the Administrative Conference Room on the morning of March 6, 2013, the provider's Facilities Maintenance Engineer stated that a new fire alarm system had recently been installed in the facility. He could not confirm that this project had been submitted to the Department for review. The surveyor notes that only minimal testing of the building fire alarm system, relative to the loudness of the notification devices, was conducted on this date.

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Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

A. Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517.

Findings include:

1. During the morning of 06/26/12 the surveyor along with the facility representatives observed, Critical panels CLB, CLB-A-CR, LLB-A-CR, and LLB-B-CR are all serving fire alarm panels that are required to be served by the life safety branch of the emergency power system by NFPA70, Section 517-32.

2. Corrected 03/06/13.

3. During the morning of 06/26/12 the surveyor along with the facility representatives observed Panel LLA serving a mix of loads that need to be moved to the proper branches of the emergency power system as required by NFPA-70, Section 517-30 through 34.

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