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Based on document review and interview with the Administrator, the facility failed to maintain an approved Emergency Management Plan for the current year. Annual review of the plan is required to enable the facility to be in compliance with county emergency management procedures and requirements for health care facilities in the event of an emergency or disaster.

The findings include:

During the Fire & Life Safety document review of the facility with the Administrator on 09/28/20 it was found that the Emergency Management Plan had not been submitted for the current year the last approved plan on file was 7/2019. The Administrator verified these findings at the time it was discovered. Plans must be updated annually per F.A.C 59A-5.018-4 12 and 9.7.4.1, NFPA 10.

Based on observation and interview with the Administrator, the facility failed to maintain proper maintenance of the Fire/Smoke doors. This condition could result in (2) Smoke Compartments to become involved in a Fire/Smoke situation. This could allow fire, smoke and fire gasses to enter the compartment, which would impede or deny the exiting of occupants in an emergency and result in harm to the occupants from the dangers of the emergency.

The findings include:

During the Fire & Life Safety tour of the facility with the Administrator on 09/28/20, it was observed that several Smoke doors were not closing properly,
1. Self-closing double doors on the Administration Hall not closing properly, over a half inch gap in doors
2. Door going into Lab, hole in door were a lock was removed
The Facility Administrator verified these findings at the times observed.
NFPA 101, (2012 edition,) Chapter 19, 19.3.6.3.5, "Doors shall be provided with a means for keeping the door closed that is acceptable to the AHJ."

Based on record review and interview with the Administrator, the facility failed to conduct and document the required annual Internal and External disaster drills and quarterly fire drills. These drills increase the knowledge of staff of the action to take in an emergency situation and helps prevent confusion to occupants and staff in the event of an emergency.

The findings include:

During the Fire & Life Safety record review of the facility with the Administrator on 09/28/20, it was observed that the annual Internal/External disaster drills had not been done. In addition, the facility did not complete the required fire drills per year. The Administrator verified these findings at the times observed. Each organizational cooperation entity shall implement two or more (Internal & External) specific responses of the emergency operations plan during each year. According to CMS, drills must be separated by 4 to 7 months. Fire drills should be implemented one per shift per quarter.
F.A.C. 59A