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FERRELL HOSPITAL COMMUNITY FOUNDATIONS
No Description Available
Tag No.: K0038
Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from reaching an exit under fire conditions.
Findings include:
A. At 1:59 PM on April 9, 2013, the exterior egress path from the Clinic east exit door (which serves as an egress path for the health care occupancy) was observed to not be complete to a public way as required by 7.7.1. because no stable walking surface to the public way is provided.
On the 05/31/13 revisit, the condition cited on the April 9, 2013, survey remains unchanged, therefore, the Provider remains in noncompliance.
No Description Available
Tag No.: K0067
Based on staff interview, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A. This deficiency could affect any patients, staff, or visitors in the building because the failure of the fire dampers could permit fire or smoke to pass through fire and smoke rated assemblies.
Findings include:
A. During an interview held in an Administrative Office 8:39 AM on April 10, 2013, the provider's Facilities Director confirmed that fire dampers are not tested every 4 years as required by NFPA 90A 1999 3-4.7.
On 05/31/13 revisit, the condition cited on the April 10, 2013, survey remains unchanged, therefore, the Provider remains in noncompliance.
No Description Available
Tag No.: K0130
Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.
Findings include:
A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.