Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 65C0001001 (X3) Date Survey Completed 02/08/2019
Name of Provider or Supplier Hafa Adai Specialist Group, Llp Street Address, City, State Sunflower Villa, 280 Pale San Vitores, Tamuning, GU
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
K0345 Fire Alarm System - Testing and Maintenance
CFR(s): NFPA 101

Fire Alarm Systems - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72


This STANDARD is not met as evidenced by:
Based on an interview with the office manager the facility has failed to maintain and test the facility's fire alarm control system as required. This could lead to a failure of the fire alarm control system which would prevent it from working as intended. This could expose staff and patients, potentially under general anesthesia, to an increased risk of injury or death due to a fire.



Findings include:



On February 1, 2019 at approximately 2PM, while performing record review the office manager was asked to provide records showing that the fire alarm control system had been maintained and tested on a semi-annual and annual basis. The office manager asked for examples of the testing and maintenance requirements.



The following are those presented as examples:



* Sealed lead acid batteries are required to be inspected and tested every six months.

* The battery charger is tested annually.

* The batteries undergo an annual 30 minute discharge test.



These and other requirements are listed in Ch. 14, NFPA 72, Fire Alarm and Signaling Code 2010 Edition.



The office manager said none of the inspections and tests listed as examples had been performed and that he had no records to show that they had been done.