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The facility did not ensure that fire drills were held at unexpected times under varying conditions at least quarterly on each shift as required by section # 19.7.1.4 of the referenced, "Life Safety Code"

1. On 01/24/17 at 10:30 AM, the surveyor was not provided with documentation by the Director of Safety & Security to indicate that a fire drill was conducted on the first shift during the first quarter of 2016, as required by section # 19.7.1.4 of the "Life Safety Code; i.e., drill conducted at 6:15 AM, third shift and lacked the activation of the fire alarm.

2. On 01/24/17 at 10:35 AM, the surveyor was not provided with documentation by the Director of Safety & Security to indicate that a fire drill was conducted on the second shift during the fourth quarter of 2016, as required by section # 19.7.1.4 of the "Life Safety Code; i.e., documentation provided the time as 6:00 that would indicated the drill was conducted on the third shift without the activation of the fire alarm, the facility documents using military time so if the drill was on second shift the time should be noted as 18:00.

The facility did not ensure that piped in medical gas systems are in compliance with NFPA 99, 5.1.14.2 Maintenance Programs.

On 01/24/17 at 1:00 PM, the surveyor was not provided with documentation by the Head of the Respiratory Department to indicate that deficiencies note on the inspection and testing of the piped in medical gas system had been corrected; i.e., Manifold Room A103 and A111 source valves not locked open and rooms lacks functioning exhaust as required by NFPA 99.