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Based on observation and interview with staff, the facility failed to provide a fire alarm system that is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The system has an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4 Findings include:

The facility notified the vendor who repairs and test the fire alarm system, the facility requested that the Magnetic Door locks that control egress and access for adolescent unit of the hospital be repair because the lock was not functioning properly. The access door of the adolescent unit after repair was affected and was not locking. The facility failed to require the vendor to inspect all devices affected by the initial trouble and test another 10% of devices up to 50 devices and provide a Re-Acceptance 4 page document signed by a representative of the building. The document shall be kept for two years.

On January 3, 2013 Simplex/Grinell completed the annual test of the hospitals alarm syste, however the facility failed to require the vendor to provide a re-acceptance test for upgrades that were completed.

Based on observation and interview with staff, the facility failed to provide Heating, ventilating, and air conditioning that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2 Findings include:

4 Exhaust fans located on the roof were not working. The preventive maintenance system of the hospital did not include the process of identifying equipment that is not working.

Based on observation and interview with staff, the facility failed to provide a Type I Essential Electrical System powered by a generator with a transfer switch and separate power supply. The EES is in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4. Findings include:

The Generator was inspected and informed the facility that a control switch was in need of repair. At the time of the survey the switch has not been replaced.

Based on observation and interview with staff, the Governing Body responsible for the structure that has the elements of hospital operation for Building Design, Purchasing, inspection,maintenance schedules,and training programs failed to oversee implementation of said responsibilities. NFPA 99 1999 edition chapter 12-2.1 Findings include:

The facility has failed to Implement a Preventive Maintenance Program that covers all equipment and building services. A preventive maintenance program program shall be established and approved by the governing body . The water softener for the hospital located in the boiler room was not working.

Based on observation and interview with staff, the facility failed to provide a fire alarm system that is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The system has an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4 Findings include:

The facility notified the vendor who repairs and test the fire alarm system, the facility requested that the Magnetic Door locks that control egress and access for adolescent unit of the hospital be repair because the lock was not functioning properly. The access door of the adolescent unit after repair was affected and was not locking. The facility failed to require the vendor to inspect all devices affected by the initial trouble and test another 10% of devices up to 50 devices and provide a Re-Acceptance 4 page document signed by a representative of the building. The document shall be kept for two years.

On January 3, 2013 Simplex/Grinell completed the annual test of the hospitals alarm syste, however the facility failed to require the vendor to provide a re-acceptance test for upgrades that were completed.

Based on observation and interview with staff, the facility failed to provide Heating, ventilating, and air conditioning that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2 Findings include:

4 Exhaust fans located on the roof were not working. The preventive maintenance system of the hospital did not include the process of identifying equipment that is not working.

Based on observation and interview with staff, the facility failed to provide a Type I Essential Electrical System powered by a generator with a transfer switch and separate power supply. The EES is in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4. Findings include:

The Generator was inspected and informed the facility that a control switch was in need of repair. At the time of the survey the switch has not been replaced.

Based on observation and interview with staff, the Governing Body responsible for the structure that has the elements of hospital operation for Building Design, Purchasing, inspection,maintenance schedules,and training programs failed to oversee implementation of said responsibilities. NFPA 99 1999 edition chapter 12-2.1 Findings include:

The facility has failed to Implement a Preventive Maintenance Program that covers all equipment and building services. A preventive maintenance program program shall be established and approved by the governing body . The water softener for the hospital located in the boiler room was not working.