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ELGIN MENTAL HEALTH CENTER
Emergency Lighting
Tag No.: K0291
Based on record review and interview, it was determined that the facility failed to provide proof that battery powered emergency lighting is maintained in accordance with Code requirements. This deficient practice could affect patients and staff in areas of the building under emergency conditions if emergency lights are not properly maintained.
The finding is:
On 5/2/2022 at 12:30pm while in the company of the CE and BA, it was determined after document review and interview that evidence was not provided to verify the monthly 30-second testing and the annual 90-minute testing requirements for battery powered emergency lighting are met in accordance with 19.2.9.1, 7.9.3.1.1.
Exit Signage
Tag No.: K0293
Based on record review and interview, it was determined that the facility failed to provide proof that exit signs are maintained in accordance with Code requirements. Failure to maintain exit signs can compromise the ability of occupants to find available exits from the building during a required evacuation due to a fire/smoke event.
The finding is:
On 5/2/2022 at 12:30pm while in the company of the CE and BA, it was determined after document review and interview that evidence was not provided to verify visual inspection of all exit signs at intervals not to exceed 30 days in accordance with 19.2.10.1, 7.10.9.1.
Portable Fire Extinguishers
Tag No.: K0355
Based on record review and interview, it was determined that the facility failed to provide proof that portable fire extinguishers are maintained in accordance with Code requirements. Failure to document maintenance of portable fire extinguishers can result in failure of equipment to perform as intended when needed during a fire event.
The finding is:
On 5/2/2022 at 12:30pm while in the company of the CE and BA, it was determined after document review and interview that evidence was not provided to verify fire extinguishers are maintained on an annual basis to comply with NFPA 10-2010, 7.3.1.1
HVAC
Tag No.: K0521
Based on record review and interview, it was determined that the facility failed to provide proof of testing of HVAC fire safety devices in accordance with Code requirements. Faillure of protective devices during a fire event risk safety of patients, staff and visitors.
The finding is:
On 5/2/2022 at 12:30pm while in the company of the CE and BA, it was determined after document review and interview that evidence of fire/smoke damper testing was not be provided for the building in accordance with NFPA 80-2010, 9.4 & NFPA 105-2010, 6.5.2.