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Based on observation, interview with staff, the facility failed to conduct Fire Drills that are held at unexpected times, under varying conditions, at least quarterly on each shift. The staff shall be familiar with procedures and be aware that drills are part of established routine. The responsibility for planning and conducting drills shall be assigned to competent persons who are qualified to exercise leadership. Where drills are conducted between 9 PM and 6 AM a coded announcement may be used instead of audible alarms. Findings include:

1)Review of the Fire Drill documentation, "FIRE DRILL AND FIRE ALARM TEST" conducted in 2013, noted that the facility failed to establish the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
(9) Who participated

2) Employees for the Mental Health Agency located in the north east end of the hospital were not provided with procedures that are part of a established routine or tested to familiarize with procedures that are assigned. Mental Health Staff was not trained and documented to be qualified to exercise leadership in the event of an emergency. Staff indicated that no one has provided them with area specific training and the facility could not provide documentation of training.

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



1) Fresh Air Intakes installed on the two HVAC units over Emergency Rooms were not 25 feet from exhaust vents, plumbing vents, etc.

2) Emergency Department Waiting room is not provided with negative air in accordance with Hospital Standards Chapter 667 Appendix A. Provide documentation that the room has a minimum of 2 outside air exchanges per hour, with a minimum of 12 air exchanges per hour, and document the air is exhausted directly outside or is provided with a HEPA filter in the return in accordance with appendix A, notes #14 and #15.

3) Provide Mechanical (MEP) drawing that depicts Exhaust Fans; exhaust fans on the roof were not working. Exhaust Fans not connected shall be removed or covered ; exhaust fans that are needed shall be repaired. Provide Test and Balance Report for all rooms / areas served by exhaust fans. Air Exchanges for all rooms shall be tested and maintained in accordance with manufacturer's specifications and Hospital Standards Chapter 667.

4) Facility did not have a current Preventive Maintenance Program for HVAC equipment. Facility could not provide a inventory of equipment or a preventive maintenance program in accordance with manufacturer's specifications.

5) Room 102 is the Isolation Room. The exhaust fan has been removed, along with the monitor. Provide a Test Balance Report that depicts room with Air Exchanges in accordance with Appendix A.

Based on observation and interview with staff, the facility failed to provide and maintain piped in medical gas systems that comply with NFPA 99, Chapter 4. Findings include:

1) The bulk oxygen site did not have a cement slab to separate liquefied oxygen from ground surface. Fence protecting Bulk Oxygen Tank has been run over so many times, that very little of the fence structure is left intact. The pipe supplying the hospital is not protected, a 12'' cement block was over the pipe protecting from lawn mower.

2) The is no emergency liquid fill station located on the building in accordance with NFPA 99 1999 edition chapter 4-3.1.1.8 (h).

1) Based on observation , interview with staff, the facility failed to provide qualification and training of personnel concerned with the application and maintenance of electric appliances, including physicians, nurses, nurse aids, engineers, technicians, and orderlies. Staff shall be cognizant of the risks associated with their use and to achieve the end results the hospital shall provide appropriate programs of continuing education for its personnel. This program shall include periodic review of manufacturers ' safety guidelines and usage requirements for electrosurgical units and similar appliances in accordance with NFPA 99, 1999 edition, chapter 7-6.5.1. Findings include:

a) There was no documentation / program available that provided yearly training for equipment or usage requirements of appliances for staff in the hospital. The was no documentation that staff was trained to shut off Utilities / Equipment, Fire Suppression Systems, Medical Gas Piping and Alarms, or Dish Washing procedures and log.

2) Based on review of the lease agreement between the Hospital and Mental Health Out- Patient Therapy Provider, the facility failed to provide the following:

a) Separate the Mental Health Out- Patient Therapy Department from the hospital by a fire barrier of not less than 2 hour 18.1.2.2.

b) The facility failed to in-service staff on emergency preparedness. The hospital failed to include Mental Health employees with Operation Features and Evacuation procedures.

c) The host facility failed to in-services staff regarding Portable space heaters, space heaters are prohibited in health care occupancies NFPA 101 18.7.8 Portable space heater was found in the Mental Health Providers area .

Based on observation and interview with staff, the facility failed to provide Electrical wiring and equipment that is Maintained, Tested, and Inserviced in accordance with NFPA 70, National Electrical Code. 9.1.2, and NFPA 99. Findings include:


1) The Emergency Generator and Transfer Switches located adjacent to the Boiler Room were not provided with a 1- 1/2 hour battery back up light.

2) There was no separation from the boiler room to the emergency generator room. The door knob assembly was removed from the UL Rated door assembly.

3) Impedance Testing for new circuits, new receptacles installed in the Emergency Room has not been preformed. No documentation or record keeping was maintained in accordance with NFPA 99 1999 edition chapter 3-3.3.2.1, 3-3.4.3 for any receptacles in the facility.

4) Receptacles in patient care areas had not been tested for physical integrity, continuity of ground, correct polarity, and retention of grounding blade in accordance with 3-3.3.3

5) Emergency Branches / Panels located in the facility were not marked. There was no way to determine if the Life Safety Branch , Critical Care Branch, and Equipment Branch were separated in accordance with NFPA 99 1999 edition, chapter 3-4. Facility could not provide a singleline diagram that depicted electrical routing.

6) Nurse Call light in Physical Therapy Rest Room did not alert at the nurses station. Director of Engineering indicated that no Preventive Maintenance check had been performed for the system.

Based on observation, interview with staff, the facility failed to conduct Fire Drills that are held at unexpected times, under varying conditions, at least quarterly on each shift. The staff shall be familiar with procedures and be aware that drills are part of established routine. The responsibility for planning and conducting drills shall be assigned to competent persons who are qualified to exercise leadership. Where drills are conducted between 9 PM and 6 AM a coded announcement may be used instead of audible alarms. Findings include:

1)Review of the Fire Drill documentation, "FIRE DRILL AND FIRE ALARM TEST" conducted in 2013, noted that the facility failed to establish the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
(9) Who participated

2) Employees for the Mental Health Agency located in the north east end of the hospital were not provided with procedures that are part of a established routine or tested to familiarize with procedures that are assigned. Mental Health Staff was not trained and documented to be qualified to exercise leadership in the event of an emergency. Staff indicated that no one has provided them with area specific training and the facility could not provide documentation of training.

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



1) Fresh Air Intakes installed on the two HVAC units over Emergency Rooms were not 25 feet from exhaust vents, plumbing vents, etc.

2) Emergency Department Waiting room is not provided with negative air in accordance with Hospital Standards Chapter 667 Appendix A. Provide documentation that the room has a minimum of 2 outside air exchanges per hour, with a minimum of 12 air exchanges per hour, and document the air is exhausted directly outside or is provided with a HEPA filter in the return in accordance with appendix A, notes #14 and #15.

3) Provide Mechanical (MEP) drawing that depicts Exhaust Fans; exhaust fans on the roof were not working. Exhaust Fans not connected shall be removed or covered ; exhaust fans that are needed shall be repaired. Provide Test and Balance Report for all rooms / areas served by exhaust fans. Air Exchanges for all rooms shall be tested and maintained in accordance with manufacturer's specifications and Hospital Standards Chapter 667.

4) Facility did not have a current Preventive Maintenance Program for HVAC equipment. Facility could not provide a inventory of equipment or a preventive maintenance program in accordance with manufacturer's specifications.

5) Room 102 is the Isolation Room. The exhaust fan has been removed, along with the monitor. Provide a Test Balance Report that depicts room with Air Exchanges in accordance with Appendix A.

Based on observation and interview with staff, the facility failed to provide and maintain piped in medical gas systems that comply with NFPA 99, Chapter 4. Findings include:

1) The bulk oxygen site did not have a cement slab to separate liquefied oxygen from ground surface. Fence protecting Bulk Oxygen Tank has been run over so many times, that very little of the fence structure is left intact. The pipe supplying the hospital is not protected, a 12'' cement block was over the pipe protecting from lawn mower.

2) The is no emergency liquid fill station located on the building in accordance with NFPA 99 1999 edition chapter 4-3.1.1.8 (h).

1) Based on observation , interview with staff, the facility failed to provide qualification and training of personnel concerned with the application and maintenance of electric appliances, including physicians, nurses, nurse aids, engineers, technicians, and orderlies. Staff shall be cognizant of the risks associated with their use and to achieve the end results the hospital shall provide appropriate programs of continuing education for its personnel. This program shall include periodic review of manufacturers ' safety guidelines and usage requirements for electrosurgical units and similar appliances in accordance with NFPA 99, 1999 edition, chapter 7-6.5.1. Findings include:

a) There was no documentation / program available that provided yearly training for equipment or usage requirements of appliances for staff in the hospital. The was no documentation that staff was trained to shut off Utilities / Equipment, Fire Suppression Systems, Medical Gas Piping and Alarms, or Dish Washing procedures and log.

2) Based on review of the lease agreement between the Hospital and Mental Health Out- Patient Therapy Provider, the facility failed to provide the following:

a) Separate the Mental Health Out- Patient Therapy Department from the hospital by a fire barrier of not less than 2 hour 18.1.2.2.

b) The facility failed to in-service staff on emergency preparedness. The hospital failed to include Mental Health employees with Operation Features and Evacuation procedures.

c) The host facility failed to in-services staff regarding Portable space heaters, space heaters are prohibited in health care occupancies NFPA 101 18.7.8 Portable space heater was found in the Mental Health Providers area .

Based on observation and interview with staff, the facility failed to provide Electrical wiring and equipment that is Maintained, Tested, and Inserviced in accordance with NFPA 70, National Electrical Code. 9.1.2, and NFPA 99. Findings include:


1) The Emergency Generator and Transfer Switches located adjacent to the Boiler Room were not provided with a 1- 1/2 hour battery back up light.

2) There was no separation from the boiler room to the emergency generator room. The door knob assembly was removed from the UL Rated door assembly.

3) Impedance Testing for new circuits, new receptacles installed in the Emergency Room has not been preformed. No documentation or record keeping was maintained in accordance with NFPA 99 1999 edition chapter 3-3.3.2.1, 3-3.4.3 for any receptacles in the facility.

4) Receptacles in patient care areas had not been tested for physical integrity, continuity of ground, correct polarity, and retention of grounding blade in accordance with 3-3.3.3

5) Emergency Branches / Panels located in the facility were not marked. There was no way to determine if the Life Safety Branch , Critical Care Branch, and Equipment Branch were separated in accordance with NFPA 99 1999 edition, chapter 3-4. Facility could not provide a singleline diagram that depicted electrical routing.

6) Nurse Call light in Physical Therapy Rest Room did not alert at the nurses station. Director of Engineering indicated that no Preventive Maintenance check had been performed for the system.