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Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm systems was installed in accordance with 19.3.4.1. NFPA 72, 17.7.4.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. A.17.7.4.1 states detectors should not be located in a direct airflow or closer than 36 inches. This deficient practice could affect patients, visitors, and staff in the foyer immediately outside the A unit.

Findings include:

Based on observation with the Chief Executive Officer and the Operations Supervisor / Security Officer on 05/10/18 at 12:31 p.m., the foyer area immediately outside the A unit had a smoke detector approximately 14 inches from an air duct. Based on interview at the time of the observation, both the Chief Executive Officer and the Operations Supervisor / Security Officer acknowledged the aforementioned condition, and verified the above listed measurement. This smoke detector was then later checked, at the request of the Chief Executive Officer, and found to have been moved by the maintenance staff to a satisfactory area that met the 36 inch or more distance from a direct airflow requirement.

Based on record review, observation and interview; the facility failed to document sprinkler system inspections in accordance with NFPA 25. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.4.2 states gauges on dry pipe sprinkler systems shall be inspected weekly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 5.1.2 states valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 13. Section 13.3.2.1 states all valves shall be inspected weekly. Section 4.3.1 states records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request. This deficient practice could affect all patients, visitors, and staff in the facility.

Findings include:

Based on review of Brenneco's "Quarterly Fire System Sprinkler Inspection" documentation dated 03/26/2018, 12/19/2017, 09/18/2017, and 06/14/17 with the Chief Executive Officer and the Operations Supervisor / Security Officer on 05/10/18 during record review at 11:17 a.m., weekly sprinkler gauge inspection documentation was not available for review. In addition, weekly inspection documentation for all sprinkler system control valves was also not available for review. Based on interview at the time of record review and observation, the Chief Executive Officer and the Operations Supervisor / Security Officer acknowledged weekly sprinkler system gauge and control valve inspection documentation for the aforementioned periods was not available for review and added that they did not know they were required to be inspected as such. During the exit, no additional information or evidence could be provided contrary to this deficient finding.

Based on record review, observation and interview; the facility failed to provide a written plan that addressed all components in 1 of 1 written fire plans. LSC 19.7.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire
Section 19.7.2.3.2 states: All health care occupancy personnel shall be instructed in the use of a code phrase to ensure transmission of an alarm under any of the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person.
(2) During a malfunction of the building fire alarm system.
This deficient practice could affect all patients, visitors, and staff in the facility.

Findings include:

Based on review of the "Disaster Manual - Fire Protection Plan" documentation with the Chief Executive Officer and the Operations Supervisor / Security Officer during record review at 10:45 a.m. on 05/10/18, the written fire safety plan did not address the coded announcement or page when the PBX operator was not present, or after normal business hours. Based on interview at the time of record review, both the Chief Executive Officer and the Operations Supervisor / Security Officer acknowledged that there was no documentation as to how the coded announcement was made when the PBX operator was not on site. The Chief Executive Officer stated that staff could make the announcement from any phone within the facility, but agreed that their written fire safety plan did not state that information. During the exit conference, no additional information or evidence could be provided contrary to this deficient finding.

Based on record review and interview, the facility failed to conduct quarterly fire drills for 1 of 4 quarters. LSC 19.7.1.6 requires drills to be conducted quarterly on each shift under varied conditions. This deficient practice could affect all patients, visitors, and staff in the facility.


Findings include:

Based on record review of the "Fire Drill Report" form with the Chief Executive Officer and the Operations Supervisor / Security Officer on 05/10/18 at 11:18 a.m., there was no documentation available for review of a second quarter (April, May, June) of 2017 fire drill for either the 1st or 3rd shifts. Based on interview at the time of record review, the Chief Executive Officer and the Operations Supervisor / Security Officer acknowledged the fire drills were missing and indeed not available for review. During the exit conference, no additional information or evidence could be provided contrary to this deficient finding.

Based on record review and interview, the facility failed to ensure 1 of 1 emergency generators was allowed a 5 minute cool down period after a load test. Chapter 6.4.4.1.1.4(a) of 2012 NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, the Standard for Emergency and Standby Powers Systems, Chapter 8. NFPA 110, 6.2.10 Time Delay on Engine Shutdown requires that a minimum time delay of 5 minutes shall be provided for unloaded running of the Emergency Power Supply (EPS) prior to shut down. This delay provides additional engine cool down. This time delay shall not be required on small (15 kW or less) air-cooled prime movers. This deficient practice could affect all patients, as well as staff and visitors in the facility.

Findings include:

Based on record review with the Chief Executive Officer and the Operations Supervisor / Security Officer at 10:43 a.m. on 05/10/18, the generator log form documented the generator was tested monthly for at least 30 minutes under load, however, there was no documentation on the form that showed the generator had a cool down time following its load test. Based on interview at the time of record review, the Chief Executive Officer and the Operations Supervisor / Security Officer advised that they did not know about the above mentioned generator requirement. During the exit, no additional information or evidence could be provided contrary to this deficient finding.