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)
K0353 Sprinkler System - Maintenance and Testing
CFR(s): NFPA 101

Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25


This STANDARD is not met as evidenced by:
Based on interview and record review the facility has failed to inspect, maintain and test the automatic sprinkler system on a monthly, quarterly, semi-annual and annual interval, as required. Failure to perform these required operations could result in the failure of the sprinkler system to function as intended. This could cause a fire to spread more quickly and with greater intensity resulting in injury or death.



Findings include:



On January 31, 2019 at approximately 2PM the office manager was asked to provide records of any sprinkler inspection, maintenance and testing records performed within the past year. The office manager provided an invoice dated December 7, 2018 for services performed by a company which declared on the document that the inspection of the facility's standpipe system was performed according to the National Fire Protection Association (NFPA) Standard 14, "Standard for the Installation of Standpipe and Hose Systems".



The office manager was informed that CMS required that inspection, maintenance and testing on sprinkler systems were to be performed according to NFPA 25, "Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems" and that these were required to be performed on monthly, quarterly, semi-annual, annual and 5 years intervals. The office manager said he was not aware of this requirement.

The office manager was asked if the facility if any other services were performed on the facility's sprinkler system. The office manager said that no other services were performed and that he had no other sprinkler system records for the year 2018.