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This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 18.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 2-3.4.5.1.2, 2-3.5.1. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting all patients, staff, and visitors of the facility.


Findings include:


On facility tour between 9:00 AM to 4:00 PM on 06/06/2012, observation revealed, that the following smoke detectors were located within 3 feet of air supply diffuser:

1. The detector head located in the Health Information Office
2. The detector head located in the Emergency Department's main entry.


This deficient practice was verified by the Maintenance Manager (JV).

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 2-3.4.5.1.2, 2-3.5.1. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting all patients, staff, and visitors of the facility.


Findings include:


On facility tour between 9:00 AM to 4:00 PM on 06/06/2012, observation revealed, that the following smoke detectors were located within 3 feet of air supply diffuser:

1. The detector head located in the Health Information Office
2. The detector head located in the Emergency Department's main entry.


This deficient practice was verified by the Maintenance Manager (JV).

This STANDARD is not met as evidenced by:

Based on observations, the automatic sprinkler system is not installed and maintained in accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems (99). The failure to maintain the sprinkler system in compliance with NFPA 13 (99) could allow damage to the sprinkler piping that would cause failures in the system and affect all the patients, visitors and staff of the facility.

Findings include:

On facility tour between 9:00 AM to 4:00 PM on 06/06/2012, observations reveled that there were escutcheon rings missing in the Lab waiting room, by the Emergency room reception desk, and inside the Central Sterile Soiled Utility room.


This deficient practice was verified by the Maintenance Manager (JV).

Based on observations, the automatic sprinkler system is not installed and maintained so that at least a local alarm will sound when the valves are closed, in accordance with NFPA 101 (2000), Chapter 9, Section 9.7.2.1 and NFPA 72 (1999) and NFPA 13 (1999).accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems (99). The failure to maintain the sprinkler system in compliance could allow for the failure of the fire sprinkler system and affect all the patients, visitors and staff of the facility.


FINDINGS INCLUDE:

On facility tour between 9:00 AM to 4:00 PM on 06/06/2012, observations revealed that the facility's fire sprinkler water main supply outside screw and yolk valve was not equipped with the require electronically monitored tamper switch


This deficient practice was verified by the Maintenance Manager (JV).

This STANDARD is not met as evidenced by:

Observations revealed that the oxygen and medical gas systems are not properly labeled in accordance with NFPA 99 Standards for Health Care Facilities (1999 edition). This deficient practice could create confusion in identifying medical gas piping located in the interstitial spaces and could negatively impact all patients and staff in an emergency.

Findings include:

On facility tour between 9:00 AM to 4:00 PM on 06/06/2012, it was observed that the medical gas emergency shut off valves located in the West patient wing did not have the proper labeling on the vacuum line vale.


This deficient practice was verified by the Maintenance Manager (JV).

This STANDARD is not met as evidenced by:

Based on review of reports, records and interview, it was determined that the facility failed vary the times of the fire drills and also failed to conduct the required number of fire drill in the last 12-month period. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect the safety of all patients, visitors and staff.

Findings include:

On facility tour between 9:00 AM to 4:00 PM on 06/06/2012, during a documentation review of the available fire drill reports and interview with the Maintenance Manager (JV), the following deficiencies were revealed:

1. 3 in the 10 AM hour,
2. 3 in the 1 PM hour,
3. 2 in the 2 PM hour,
4. 2 in the 4 PM hour,
5. failed to conduct 2 of 4 second shift fire drills, and
6. failed to conduct 2 of 4 overnight shift fire drills.

This deficient practice was verified by the Maintenance Manager (JV).

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 18.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 2-3.4.5.1.2, 2-3.5.1. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting all patients, staff, and visitors of the facility.


Findings include:


On facility tour between 9:00 AM to 4:00 PM on 06/06/2012, observation revealed, that the following smoke detectors were located within 3 feet of air supply diffuser:

1. The detector head located in the Health Information Office
2. The detector head located in the Emergency Department's main entry.


This deficient practice was verified by the Maintenance Manager (JV).

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 2-3.4.5.1.2, 2-3.5.1. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting all patients, staff, and visitors of the facility.


Findings include:


On facility tour between 9:00 AM to 4:00 PM on 06/06/2012, observation revealed, that the following smoke detectors were located within 3 feet of air supply diffuser:

1. The detector head located in the Health Information Office
2. The detector head located in the Emergency Department's main entry.


This deficient practice was verified by the Maintenance Manager (JV).

This STANDARD is not met as evidenced by:

Based on observations, the automatic sprinkler system is not installed and maintained in accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems (99). The failure to maintain the sprinkler system in compliance with NFPA 13 (99) could allow damage to the sprinkler piping that would cause failures in the system and affect all the patients, visitors and staff of the facility.

Findings include:

On facility tour between 9:00 AM to 4:00 PM on 06/06/2012, observations reveled that there were escutcheon rings missing in the Lab waiting room, by the Emergency room reception desk, and inside the Central Sterile Soiled Utility room.


This deficient practice was verified by the Maintenance Manager (JV).

Based on observations, the automatic sprinkler system is not installed and maintained so that at least a local alarm will sound when the valves are closed, in accordance with NFPA 101 (2000), Chapter 9, Section 9.7.2.1 and NFPA 72 (1999) and NFPA 13 (1999).accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems (99). The failure to maintain the sprinkler system in compliance could allow for the failure of the fire sprinkler system and affect all the patients, visitors and staff of the facility.


FINDINGS INCLUDE:

On facility tour between 9:00 AM to 4:00 PM on 06/06/2012, observations revealed that the facility's fire sprinkler water main supply outside screw and yolk valve was not equipped with the require electronically monitored tamper switch


This deficient practice was verified by the Maintenance Manager (JV).

This STANDARD is not met as evidenced by:

Observations revealed that the oxygen and medical gas systems are not properly labeled in accordance with NFPA 99 Standards for Health Care Facilities (1999 edition). This deficient practice could create confusion in identifying medical gas piping located in the interstitial spaces and could negatively impact all patients and staff in an emergency.

Findings include:

On facility tour between 9:00 AM to 4:00 PM on 06/06/2012, it was observed that the medical gas emergency shut off valves located in the West patient wing did not have the proper labeling on the vacuum line vale.


This deficient practice was verified by the Maintenance Manager (JV).