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Based on observation and staff interview, the facility failed to ensure that an emergency lighting of at least 90 minutes duration is provided in accordance with NFPA 101-2012 Life Safety Code 7.9.

Findings include:

On 06/29/2017 at approximately 11:25 AM, it was observed that there was no emergency lighting in the two (2) stair case enclosures, leading to the first floor from the second floor of the Extension Clinic.

An interview with Staff A, Deputy Director of Administration and Staff B, Life Safety Manager, on 6/29/2017 at 11:32 AM, confirmed these findings.

Based on interview and record review, it was identified that the facility failed to (a) ensure that the fire alarm system is tested and maintained in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code, and (b) that records of system acceptance, maintenance and testing are readily available.

Finding includes:

Review of the facility's record for the fire alarm system, revealed that the facility did not have documented evidence of testing and maintenance of its fire alarm system installed at the Extension Clinic. The only record of testing provided to the surveyors was dated 11/30/2016.

An interview with Staff A, Deputy Director of Administration and Staff B, Life Safety Manager, at approximately 10:30 AM on 06/30/2017, revealed that the facility did not have access to any other testing and maintenance records

Based on observation, staff interview and record review, the facility failed to ensure that the Automatic sprinkler systems are inspected, tested, and maintained in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-based fire protection Systems.

Findings include:

On 06/29/2017 at 12:15 PM, it was observed that the Sprinkler Room at the Extension Clinic did not have a spare sprinkler box containing two of every sprinkler heads installed in the facility, and a wrench, as required. An interview with Staff A and Staff B, on 06/29/2017 at 12:20 PM confirmed this finding.

On 06/30/2017 at approximately 10:15 AM during facility's Extension Clinic record review, it was revealed that the facility did not have documented evidence of testing and maintenance of its Automatic sprinkler system. The only record of testing provided to the surveyors was dated 11/30/2016.

An interview with Staff A, Deputy Director of Administration on 06/30/17 at approximately 10:20 AM, revealed that the facility did not ensure that the sprinkler system was tested and maintained after 11/30/2016.

Based on observation and staff interview, the facility failed to ensure that smoke barriers are constructed to a ½ hour fire resistance rating, per NFPA 101- 2012 Life Safety Code 8.5

Findings include:

On 06/26/2017 at 2:37 PM, 2 cable penetrations were observed in the one (1) hour fire /smoke barrier wall in the vicinity of Medication Room - A3-321. An interview with Staff A and Staff B on 06/26/2017 at 2:37 PM confirmed this finding.

On 06/27/2017 at approximately 11:10 AM: four (4) cable penetrations were observed in the one (1) hour fire/smoke barrier wall in the vicinity of Room A2-319. An unsealed conduit penetration was observed in the (1) hour fire /smoke barrier wall in the vicinity of the Data Room.

Interview with Staff A, Deputy Director of Administration and Staff B, Life Safety Manager on 06/27/17 at 11:10 AM, confirmed these findings.

Based on staff interview and document review, the facility failed to (a) ensure that Hospital grade receptacles at patient bed locations are tested after initial installation, replacement or servicing, (b) ensure additional testing is performed at intervals defined by the facility documented performance data and that (c) receptacles not listed as hospital grade at these locations are tested at intervals not exceeding 12 months.

Findings include:

Review of the facility's record, revealed that the facility did not have a record of testing and maintenance of the hospital grade Ground fault Circuit Interrupters (GFCI) electrical receptacles used in the main facility. It should be noted that the facility did not also have any documented performance data for these receptacles, which define when they should be tested.

An interview with Staff A, Deputy Director of Administration and Staff B, Life Safety Manager on 06/28/2017 at approximately 11:00 AM, revealed that they are not aware of the required performance testing data and were not following the manufacturer's instruction to test monthly.

Review of the facility's record for the Extension Clinic, also revealed that the facility did not have documented evidence of testing the Ground Fault Circuit Interrupters (GFCIs) and other electrical receptacles installed at the extension clinic.

An interview with Staff A on 06/30/2017 at approximately 11:00 AM, confirmed this finding.

Based on observation and staff interview, the facility failed to ensure that electrical junction boxes are maintained in good operating condition according to NFPA 70, National Electric Code.

Findings include:

On 06/28/2016 at 2:45 PM, two (2) electrical junction boxes in the Pump Room, at the main facility, were observed to lack cover plates.

Staff A, Deputy Director of Administration and Staff B, Life Safety Manager, who were present during the tour, confirmed these findings.


On 06/29/2017 at 12:15 PM, three (3) electrical junction boxes in the Extension Clinic Sprinkler Room, were observed to lack cover plates.
An interview with Staff A and Staff B on 06/29/2017 at 12:20 PM, confirmed these findings.

Based on observation and staff interview, the facility failed to ensure that all power strips are used with general precautions, and that extension cords are not used as a substitutes for fixed wiring structure.

Finding includes:

On 06/29/2017 at 11:58 AM, during a tour of the main facility, five (5) extension cords were observed to be serially connected into one another in Computer Laboratory.
An interview with Staff A, Deputy Director of Administration and Staff B, Life Safety Manager on 06/29/2017 at 12:00 PM, confirmed this finding.