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Based on observation and interview, the Facility failed to maintain doors with self-closing devices in accordance with 19.2.2.2.7 and 19.2.2.2.8.

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

FINDINGS INCLUDE:

On facility tour between 11:00 AM and 3:00 PM on 11/30/2016, observation revealed the Material Management/Storeroom door being held open with a kick down device.

This deficient practice was verified by the Facility Maintenance Director.

Based on documentation review and interview, the Facility failed to test and maintain the Fire Alarm System in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code.

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.7.5, 9.7.7, 9.7.8, and NFPA 25.


FINDINGS INCLUDE:

On facility tour between 11:00 AM and 2:00 PM on 11/30/2016, documentation reviewed revealed the following deficiencies:

a.) The Annual Fire Alarm Testing Report dated 08-05-16, indicated that the horns and strobe lights were not tested.

b.) The following discrepancies were documented on the Annual Fire Alarm Inspection Report: a LED light was not functioning on a smoke detector outside of the Administrators Office and smoke detectors were observed within 3 feet of HVAC diffusers throughout the Hospital. There was no documentation available to review that would indicate that these discrepancies were corrected.

c.) There was no documentation available to review that indicated that the DACT system was tested on a monthly basis (night shift).

This deficient practice was verified by the Facility Maintenance Director.

Based on documentation review and interview, the Facility failed to conduct Fire Drills in accordnance with 18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7.

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7.

FINDINGS INCLUDE:

On facility tour between 11:00 AM and 2:00 PM on 11/30/2016, documentation reviewed revealed that the night shift fire drills were not conducted at unexpected times under varying conditions. Fire drills were documented that they were conducted at 0645 hrs, 0630 hrs, 0615 hrs, and 0600 hrs during the past year.

This deficient practice was verified by the Facility Maintenance Director.