HospitalInspections.org

Based on review of the records and interview with the CEO and Director of Maintenance on the morning of 7/2/2025, the requirement for testing the Fire Alarm system is not met. It was indicated verbally it is tested during fire drills. No mention of activation of the alarm was listed on the report. It was also indicated testing is only done quarterly. The alarm must also be verified being sent and received at the monitoring station. No alarm logs were available at the time of inspection. Testing must be done monthly. Begin documenting testing.

Based on review of the records and interview with the CEO and Director of Maintenance on the morning of 7/2/2025, the requirement for final filter pressure drop records is not met. Based on records the filters are changed annually. No logs for monthly pressure readings were provided. Document readings.

Based observation during the walk of the facility with and interview with the Director of Maintenance on the morning of 7/2/2025, the facility failed to periodically exercise the main feeder and circuit breakers and had no records readily available. Begin logging this testing.
"EPSS circuit breakers for Level 1 system usage, including main and feed breakers between the EPS and the transfer switch load terminals, shall be exercised annually with the EPS in the "off" position." - NFPA 110, 2010, 8.4.7*. Note: "Circuit breakers should be tested under simulated overload conditions every 2 years." - NFPA 110, 2010, A.8.4.7
NFPA 99, 2012, 6.4.4.1.2.1*. "Circuit Breakers. Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer's recommendations."