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Observation between 8:45 am and 11:15 on 1/6/2011 revealed the requirement of the standard was not being met.
Findings: The lab and waiting area is in a 1 hour enclosure.
A. The door leading from the corridor to the Lab Waiting area was held open by a drop down device.
B. Penetrations and holes were observed in the wall above the ceiling.

Review of fire drill logs between 8:45 am and 11:15 on 1/6/2011 revealed the requirement of 2000 NFPA 101, 19.7.2 was not being met.
Findings: Actual time of fire drills were not indicated on the fire drill logs.

Observation between 8:45 am and 11:15 on 1/6/2011 revealed facility failed to provide an acceptable cross referencing of the fire alarm control panel and the panel and breaker supplying power.

The fire alarm control panel must have a label indicating the panel and breaker supplying power and the breaker in the electrical panel must have a label adjacent to the breaker indicating " FIRE ALARM CIRCUIT CONTROL " and the breaker shall be colored red.

Findings: There was not cross referencing of the fire alarm control panel and the panel and breaker supplying power.

Observation between 8:45 am and 11:15 on 1/6/2011 revealed the requirement of 2000 NFPA 101, 19.3.5 was not being met.
If there is an automatic sprinkler system it shall be installed in accordance with NFPA 13. Standard for the installation of sprinkler systems, by an approved supervised system to provide complete coverage for all portions of the building.
Findings: The closet off the conference room did not contain a sprinkler head.

Observation between 8:45 am and 11:15 on 1/6/2011 revealed the requirement of 1999 NFPA 90A, 3-4.7 was not being met.
At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary. Survey and Certification Letter S&C 10-04 LSC allows for 6 year intervals.
Findings: No documentation was found indicating this testing and maintenance had been done.

Observation and review of documentation between 8:45 am and 11:15 on 1/6/2011 revealed the requirement of NFPA 10.3.1 was not being met.
Draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.
Findings: No documentation was provided for the fire retardant properties of the cubicle curtains. No tags were located on the cubicle curtains.

Observation between 8:45 am and 11:15 on 1/6/2011 revealed the requirement of 1999 NFPA 99, 4-3.1.1.2 was not being met.
Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
Findings: The storage containers in the exterior storage area were not secured.

Records review and interview between 8:45 am and 11:15 on 1/6/2011 revealed the requirement of 1999 NFPA 99, 11-5.3.9 was not being met.
Semi-annual drills are required. At least one semi-annual drill shall rehearse mass casualty response for emergency services, disaster receiving station, or both. At least on annual after action report must be maintain for the prior year. Documentation of rehearsals for the prior three years shall be retained.
Findings: No records for disaster drills were found. Interview revealed no drills had been done.

Observation and interview between 8:45 am and 11:15 on 1/6/2011 revealed the requirement of 1999 NFPA 99, 4-3.2.2.8 (a) and 4-3.1.2.2 (b)2 was not being met.
To ensure continuous responsible observation of the med gas systems and vacuum system, the master alarm signal panels shall be located in two separate warning locations. One shall be in the office or principal working area of the person responsible for the maintenance of the system and one shall be at a continuously staffed location.
Findings: A. No master alarm panel was located in the primary work are or office of the primary person responsible for the maintenance of the med gas systems.
B. Charts were located in front of the panels obscuring the view, thus not allowing for visual observation of the alarm panel(s).

Observation between 8:45 am and 11:15 on 1/6/2011 revealed the requirement of the standard was not being met.
Findings: The medgas storage room had a sign on the door indicating no flammables were being stored within. However, oxygen cylinders were observed being stored in the room.

Review of generator logs between 8:45 am and 11:15 on 1/6/2011 revealed the requirement of NFPA 110, 8-4.8 has not been met.
A generator test must be performed every 36-48 months for at least 4 hours under full load.
Findinings: No records were found to indicate this test had been performed within the last 48 months.

Observation between 8:45 am and 11:15 on 1/6/2011 revealed the requirement of 1999 NFPA 70, 370-28(C) was not being met.
All pull boxes, junction boxes and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use.
Findings: An exterior junction box did not have a cover.