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Based on documentation review, and staff interview the facility failed to ensure fire drills were held at unexpected times and under varying conditions at least quarterly every shift. This has the potential to affect all patients receiving services from the facility. The facility census was 29 at the time of the survey.


Findings include:


Review of the fire drills for the last two quarters completed on 08/19/16 revealed the fire drills were held within an hour of each other every quarter for both first and third shifts. These findings were verified by Staff A on 08/19/16.

31007

21.3.7.2
The ambulatory health care facility shall be divided into not less than two smoke compartments.
Exception No. 1: Facilities of less than 5000 ft2 (465 m2) and protected by an approved automatic smoke detection system.
Exception No. 2: Facilities of less than 10,000 ft2 (930 m2) and protected throughout by an approved, supervised automatic sprinkler system installed in accordance with Section 9.7.
Exception No. 3: An area in an adjoining occupancy shall be permitted to serve as a smoke compartment for the ambulatory health care facility if the following criteria are met:
(a) The separating wall and both compartments meet the requirements of 21.3.7.
(b) The ambulatory health care facility is less than 22,500 ft2 (2100 m2).
(c) Access from the ambulatory health care facility to the other occupancy is unrestricted.



Based on schematic review, observation, and staff interview the facility failed to ensure the facility was divided into at least 2 smoke compartments with walls of a 1 hour fire rating. This has the potential to affect all patients receiving surgical services at the facility.


Findings include:


Tour of the facility was performed on 08/19/16 and the identified smoke wall was observed. Multiple penetrations were observed throughout the 1 hour fire rated wall. These observations were verified by Staff B at the time of the observations.