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BEAVER VALLEY HOSPITAL
No Description Available
Tag No.: K0048
Based on a review of facility fire evacuation plans for smoke compartments, the hospital plan does not specifically identify evacuation protocols from each smoke compartment as required. 19.7.2.2(6)
Findings:
The posted and written fire evacuation plan does not identify individual smoke compartments. The plan does not specify use of smoke compartments to move patients in the event of a fire in the hospital.
This finding was verified by the Director of Plant Operations.
No Description Available
Tag No.: K0050
Based on a review of fire drill documentation during the life safety survey completed on 07/31/13, the hospital did not conduct drills at one per quarter per shift as required. 19.7.1.2
Findings:
There was no documentation that a fire drill was conducted on the graveyard shift during the first quarter of 2013.
This finding was verified by the Director of Plant Operations.
No Description Available
Tag No.: K0054
Based on observation during the life safety survey completed on 07/31/13, the hospital did not provide smoke detection at all required locations.
Findings:
Integrated smoke detection was observed to be lacking from the waiting room that is open to the corridor.
This observation was made in the presence of the Director of Plant Operations.
No Description Available
Tag No.: K0062
Based on observation during the life safety survey completed on 07/31/13, the hospital did not maintain the fire sprinkler system in accordance with NFPA 13 requirements.
Findings:
Three of three pressure gauges on the fire sprinkler riser were observed to lack documentation that the gauges were either replaced or re-calibrated within the previous five years.
This observation was made in the presence of the Director of Plant Operations.
No Description Available
Tag No.: K0154
Based on a review of facility fire watch records, the hospital did not document a fire watch during an extended outage of the dry sprinkler system per CMS requirements.
Findings:
There was no documentation to verify that the hospital conducted a fire watch during the extended dry sprinkler system outage due to freezing pipe damage.
This finding was verified by the Director of Plant Operations.