HospitalInspections.org

Based upon staff interview and record review during the post survey of the facility on 05/04/2015, at approximately 1145, while accompanied by the Plant Manager and Administrator, it was discovered that the facility has failed to maintain the automatic fire sprinkler system in a reliable operating condition as required by NFPA 25. This could result in a failure of the proper operation of the automatic fire sprinkler system with the potential of fire spreading unchecked, placing patients, visitors and staff at risk. This finding was acknowledged by the Plant Manager and Administrator.

The findings include but are not limited to:

1. The AFSS is overdue for 5 year testing (last completed 01/2010).
2. There is no documentation of a quarterly inspection of the automatic fire sprinkler system for 3rd Quarter 2014 (last quarterly inspection was completed 03/07/14).

Interview and document review with Administrator and P.M. revealed that the proposed correction date for the 5 year testing is beyond the time limit allowed (35 days). The Administrator was advised that an application for a waiver for a time extension is to be sent to DOH immediately (the letter was completed in my presence at the interview) and the P.M. was able to have testing scheduled to begin this week. The quarterly testing has been addressed in a Performance Improvement Measure to ensure compliance.

Based upon staff interview and record review during the post survey of the facility on 05/04/2015, at approximately 1145, while accompanied by the Plant Manager and Administrator, it was discovered that the facility has failed to maintain the automatic fire sprinkler system in a reliable operating condition as required by NFPA 25. This could result in a failure of the proper operation of the automatic fire sprinkler system with the potential of fire spreading unchecked, placing patients, visitors and staff at risk. This finding was acknowledged by the Plant Manager and Administrator.

The findings include but are not limited to:

1. The AFSS is overdue for 5 year testing (last completed 01/2010).
2. There is no documentation of a quarterly inspection of the automatic fire sprinkler system for 3rd Quarter 2014 (last quarterly inspection was completed 03/07/14).

Interview and document review with Administrator and P.M. revealed that the proposed correction date for the 5 year testing is beyond the time limit allowed (35 days). The Administrator was advised that an application for a waiver for a time extension is to be sent to DOH immediately (the letter was completed in my presence at the interview) and the P.M. was able to have testing scheduled to begin this week. The quarterly testing has been addressed in a Performance Improvement Measure to ensure compliance. The previous citation (#3) regarding trouble with the Tamper Switch has been resolved.

Based upon staff interview and record review during the post survey of the facility on 05/04/2015, at approximately 1145, while accompanied by the Plant Manager and Administrator, it was discovered that the facility failed to maintain their emergency generator in accordance with the requirements of National Fire Protection Association (NFPA) Standard 110. This could compromise the ability of the emergency power supply to be shut down safely in the event of a generator malfunction, placing staff at risk. These findings were acknowledged by the Plant Manager and Administrator.

The findings are as follows:
1. Generator is lacking a Remote Stop Switch (per NFPA 110 3-5.5.6)


Interview and document review with Administrator and P.M. revealed that the facility has applied and recieved a letter from DOH for an extension for more time to correct this deficiency. However, the waiver has not been approved by the WSFMO as more information was required from the facility and has not yet been recieved.

Based upon staff interview and record review during the post survey of the facility on 05/04/2015, at approximately 1145, while accompanied by the Plant Manager and Administrator, it was discovered that the facility failed to maintain their emergency generator in accordance with the requirements of National Fire Protection Association (NFPA) Standard 110. This could compromise the ability of the emergency power supply to be shut down safely in the event of a generator malfunction, placing staff at risk. These findings were acknowledged by the Plant Manager and Administrator.

The findings are as follows:
1. Generator is lacking a Remote Stop Switch (per NFPA 110 3-5.5.6)

Interview and document review with Administrator and P.M. revealed that the facility has applied and recieved a letter from DOH for an extension for more time to correct this deficiency. However, the waiver has not been approved by the WSFMO as more information was required from the facility and has not yet been recieved.