HospitalInspections.org

Based on observations and staff interview, the facility failed to assure that a complete policy was in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than 4 hours in a 24 hour period. The lack of a complete written policy and procedure would result in staff failing to implement interim safety measures in the event of an emergency. Facility census was 9 and licensed for 19 at the time of survey

Findings are:
Observation and staff interview on 9-24-2019 at 10:40 AM revealed the following:

Facility failed to provide the State Fire Marshal and building insurance providers contact information in the facility fire watch policy.

During an interview on 9-24-2019 at 10:40 AM, Maintenance Staff A confirmed the contact information was not provided.

Based on observation and staff interview, the facility failed to provide an intact ceiling to ensure activation of the sprinkler system. This deficient practice would allow heat from a fire to migrate above the ceiling tile resulting in delayed activation of the fire sprinkler system allowing fire, smoke and gases to spread. Facility census was 9 and licensed for 19 at the time of survey

Finding are:
Observation and staff interview on 9-24-2019 at 11:25 AM revealed the following:

Two acoustical ceiling tiles approximately 3"x 16" in size were missing in the Kitchen located above the mop sink.

During interview on 9-24-2019 at 11:25 AM Maintenance Staff A confirmed the missing ceiling tiles.

Based on observations and staff interview, the facility failed to assure that a complete policy was in place regarding the procedures to be taken in the event that the fire sprinkler system is out of service for more than 10 hours in a 24 hour period. The lack of a complete written policy and procedure would result in staff failing to implement interim safety measures in the event of an emergency. Facility census was 9 and licensed for 19 at the time of survey.

Findings are:
Observation and staff interview on 9-24-2019 at 10:40 AM revealed the following:

Facility failed to provide the State Fire Marshal and building insurance providers contact information in the facility fire watch policy.

During an interview on 9-24-2019 at 10:40 AM, Maintenance Staff A confirmed the contact information was not provided.

Code reference:
2011 edition NFPA 25, 15.5.2 (6)
Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b)*An approved fire watch
(c)*Establishment of a temporary water supply
(d)*Establishment and implementation of an approved program to eliminate potential ignition sources and
limit the amount of fuel available to the fire
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site.