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1) Based on observation and interview with staff, the facility failed to test, and maintain the fire alarm system in accordance with NFPA 70 National Electrical Code and NFPA 72.

a) The facility could not provide an annual test report of the fire alarms system.

1) 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. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2. Findings include:

a) the lab exhaust fan was not running.

b) there was no test and balance report for those areas that are re-purposed. Er, Er waiting,

c) The ER Waiting Room is not a negative environment room.

d) There is no exhaust for the Decontamination Room

e) The exhaust for the sterilizer is not working.

f) 90% filters required for central hvac units could not be found.

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

a) The medical gas outlet to the ER Waiting did not have a zone valve, the room was opened to the egress corridor.

b) The rooms re-purposed in the ER did not have medical gas alarms, zone valves and outlets in accordance with chapter 4 of NFPA 99 1999 edition.

1) Based on observation and interview with staff, the facility failed to provide the hospital with life support equipment, have a Type I Essential Electrical System powered by a generator with a transfer switch and separate power supply. NFPA 99, 3.4.2.2, 3.4.2.1.4.

a) The emergency power generator was replaced and made larger in size ( added KW). Center for Medicaid and State Operations/Survey , Certification Group Ref: S&C-04-15 letter requires that any replacement of a system, such as a Residential Emergency Electrical System would be " major " for that system only. Thus, that system would have to meet the requirements for New buildings, not the entire building itself. Also 5.8.14 of NFPA 101 2000 edition requires that the Use of Performance-Based Design Option be implemented. The facility failed to take in consideration, design and submit notification of the following:
(1) The building was approved as a performance-based design
with certain specified design criteria and assumptions.
(2) Any remodeling, modification, renovation, change in use, or change in the established assumptions will require a re-evaluation and re-approval.
The facility did not provide one line diagram, also the facility failed to separate equipment out on the three different branches: Life Safety Branch, Critical Care Branch, and an Equipment branch 3-4.2.2.2. All areas are not wired in accordance with 3-3.2.1.2 and 3-4.2.2.4.

Based on observation and interview with staff, the facility failed to use Performance-Based Design Option found in chapter 5.8.14 of NFPA 101 2000 edition The facility failed to take in consideration, design and submit notification of the following:
(1) The building was approved as a performance-based design
with certain specified design criteria and assumptions.
(2) Any remodeling, modification, renovation, change in use, or change in the established assumptions will require a re-evaluation and re-approval.
The facility re-purposed the following areas :OR into the ER, the small ER is now the ER Waiting, Decontamination is now Housekeeping with out an approval from local jurisdiction and the department.

1) Based on observation and interview with staff, the facility failed to inspect generators weekly and exercised under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1. Findings include:

a) The emergency generator log only indicated testing for the month, the test was not carried out in accordance with Operational Maintenance &Testing, NFPA 110, 1999 edition , CHAPTER 6-4.2 . Reading from the generators gauges, run time, who ran the generator, for how long, fuel level, etc was missing on the report.

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

a) The facility failed to have an Impedance Testing Program in accordance with NFPA 99 1999 edition chapter 3-3.3.1 and Receptacle Testing in Patient care areas in accordance with 3-3.3.3

b) Throughout the hospital in all patient rooms and treatment rooms, power strips are installed for use in patient care areas. The power strips shall be labeled Hospital Grade and the required testing for Bio Medical program was not on the inventory, tested, and labeled.

c) The governing body failed to ensure that the Bio Medical Program provided by a sub contractor through the hospital ' s QAPI program to: assess the services furnished directly by hospital staff and those services provided under contract, identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities. See §482.21 QAPI.

1) Based on observation and interview with staff, the facility failed to test, and maintain the fire alarm system in accordance with NFPA 70 National Electrical Code and NFPA 72.

a) The facility could not provide an annual test report of the fire alarms system.

1) 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. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2. Findings include:

a) the lab exhaust fan was not running.

b) there was no test and balance report for those areas that are re-purposed. Er, Er waiting,

c) The ER Waiting Room is not a negative environment room.

d) There is no exhaust for the Decontamination Room

e) The exhaust for the sterilizer is not working.

f) 90% filters required for central hvac units could not be found.

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

a) The medical gas outlet to the ER Waiting did not have a zone valve, the room was opened to the egress corridor.

b) The rooms re-purposed in the ER did not have medical gas alarms, zone valves and outlets in accordance with chapter 4 of NFPA 99 1999 edition.

1) Based on observation and interview with staff, the facility failed to provide the hospital with life support equipment, have a Type I Essential Electrical System powered by a generator with a transfer switch and separate power supply. NFPA 99, 3.4.2.2, 3.4.2.1.4.

a) The emergency power generator was replaced and made larger in size ( added KW). Center for Medicaid and State Operations/Survey , Certification Group Ref: S&C-04-15 letter requires that any replacement of a system, such as a Residential Emergency Electrical System would be " major " for that system only. Thus, that system would have to meet the requirements for New buildings, not the entire building itself. Also 5.8.14 of NFPA 101 2000 edition requires that the Use of Performance-Based Design Option be implemented. The facility failed to take in consideration, design and submit notification of the following:
(1) The building was approved as a performance-based design
with certain specified design criteria and assumptions.
(2) Any remodeling, modification, renovation, change in use, or change in the established assumptions will require a re-evaluation and re-approval.
The facility did not provide one line diagram, also the facility failed to separate equipment out on the three different branches: Life Safety Branch, Critical Care Branch, and an Equipment branch 3-4.2.2.2. All areas are not wired in accordance with 3-3.2.1.2 and 3-4.2.2.4.

Based on observation and interview with staff, the facility failed to use Performance-Based Design Option found in chapter 5.8.14 of NFPA 101 2000 edition The facility failed to take in consideration, design and submit notification of the following:
(1) The building was approved as a performance-based design
with certain specified design criteria and assumptions.
(2) Any remodeling, modification, renovation, change in use, or change in the established assumptions will require a re-evaluation and re-approval.
The facility re-purposed the following areas :OR into the ER, the small ER is now the ER Waiting, Decontamination is now Housekeeping with out an approval from local jurisdiction and the department.

1) Based on observation and interview with staff, the facility failed to inspect generators weekly and exercised under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1. Findings include:

a) The emergency generator log only indicated testing for the month, the test was not carried out in accordance with Operational Maintenance &Testing, NFPA 110, 1999 edition , CHAPTER 6-4.2 . Reading from the generators gauges, run time, who ran the generator, for how long, fuel level, etc was missing on the report.

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

a) The facility failed to have an Impedance Testing Program in accordance with NFPA 99 1999 edition chapter 3-3.3.1 and Receptacle Testing in Patient care areas in accordance with 3-3.3.3

b) Throughout the hospital in all patient rooms and treatment rooms, power strips are installed for use in patient care areas. The power strips shall be labeled Hospital Grade and the required testing for Bio Medical program was not on the inventory, tested, and labeled.

c) The governing body failed to ensure that the Bio Medical Program provided by a sub contractor through the hospital ' s QAPI program to: assess the services furnished directly by hospital staff and those services provided under contract, identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities. See §482.21 QAPI.