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Based on observation and interview with staff, the facility failed to provide smoke barriers that are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. Finding:

Smoke walls are not sealed with material capable of maintaining the fire resistance of the fire barrier. This condition existed the entire length of the smoke wall.

Based on record review, the hospital failed to maintain electronic or written records of tests and to keep them readily available. Findings include:

There is no documentation there was a complete test of the fire alarm system. Testing of the HVAC shut down controls, magnetic door holds, and kitchen interface equipment was not documented on the report. The annual test was not signed by a representative of the facility and repairs of the system were not documented with a reacceptance test for repairs made.

Based on observation and interview with staff, the facility failed to provide heating equipment that complies with the provisions of section 9.2 and is installed in accordance with the manufacturer's specifications. Finding:

The boiler is not provided with an automatic shut off switch that allows safe shut down of the unit in case of an emergency.

Based on observation and interview with staff, the facility failed to provide means of egress that are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Findings:

Chairs, decorations, and equipment were located in the corridor through out the facility.

Based on observation and interview, the hospital does not have an EES is in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4. Findings:

1. The transfer switch was not provided with a 90 minute battery back up light.
2. The generator was not provided with a remote alarm enunciator that indicates the liquid fill reserve fuel supply..

3-4-4.4.2 Record keeping A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the Authority Having Jurisdiction.

Based on review of generator test records and interview with the director of engineering, the hospital doesn't keep a complete record of the performance of the electrical system. The records do not document the transfer time.

Based on review of the generator log and interview with the director of engineering, the facility failed to provide generators that are exercised under load for 30 minutes per month. Finding:

The generator logs documented the the facility was only exercising under load every quarter. The was confirmed by the Director of Engineering.

Based on observation and interview with staff, the facility failed to provide smoke barriers that are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. Finding:

Smoke walls are not sealed with material capable of maintaining the fire resistance of the fire barrier. This condition existed the entire length of the smoke wall.

Based on record review, the hospital failed to maintain electronic or written records of tests and to keep them readily available. Findings include:

There is no documentation there was a complete test of the fire alarm system. Testing of the HVAC shut down controls, magnetic door holds, and kitchen interface equipment was not documented on the report. The annual test was not signed by a representative of the facility and repairs of the system were not documented with a reacceptance test for repairs made.

Based on observation and interview with staff, the facility failed to provide heating equipment that complies with the provisions of section 9.2 and is installed in accordance with the manufacturer's specifications. Finding:

The boiler is not provided with an automatic shut off switch that allows safe shut down of the unit in case of an emergency.

Based on observation and interview with staff, the facility failed to provide means of egress that are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Findings:

Chairs, decorations, and equipment were located in the corridor through out the facility.

Based on observation and interview, the hospital does not have an EES is in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4. Findings:

1. The transfer switch was not provided with a 90 minute battery back up light.
2. The generator was not provided with a remote alarm enunciator that indicates the liquid fill reserve fuel supply..

3-4-4.4.2 Record keeping A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the Authority Having Jurisdiction.

Based on review of generator test records and interview with the director of engineering, the hospital doesn't keep a complete record of the performance of the electrical system. The records do not document the transfer time.

Based on review of the generator log and interview with the director of engineering, the facility failed to provide generators that are exercised under load for 30 minutes per month. Finding:

The generator logs documented the the facility was only exercising under load every quarter. The was confirmed by the Director of Engineering.