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Based on Disaster Manual review and interview, it was determined the written facility fire plan did not provide for the rescue of patients, isolation of fire and smoke, evacuation of smoke compartments, or the extinguishment of fire by fire extinguishers. The failed practice had the potential to affect all patients, staff, and visitors because proper response to fire could not be assured without a detailed written plan. The facility had a census of two patients on 06/27/12. The findings follow:

A. Review of the "Code Red" fire plan located in the Disaster Manual on 06/27/12 at 1205 revealed the policy and procedure for fire response in the facility did not provide instruction for the following:
1) The rescue of patients or individuals
2) The containment of fire and smoke
3) Evacuation of smoke of the immediate area and smoke compartment
4) The extinguishment of fire by the use of fire extinguishers.
B. In an interview on 06/28/12 at 1000 the Plant Services Director verified the fire plan did not address the specific actions required to be taken in the event of a fire emergency.

Reference NFPA 101 (2000 ed) Section 18.7.2.2

Based on Fire Alarm System inspection documentation review and interview, it was determined the facility failed to ensure the fire alarm system was inspected annually. The failed practice had the potential to affect the health and safety of patients, staff, and visitors because the reliability of the fire alarm system devices to alert building occupants and the fire department of a fire emergency was not assured. The facility had a census of two patients on 06/27/12. The findings follow:

A. Review of the Fire Alarm System inspection reports on 06/27/12 at 1315 revealed the most recent annual inspection of the fire alarm system occurred on 01/20/11.
B. In an interview on 06/27/12 at 1330, the Maintenance Director verified there was no further documentation available for review.

Based on interview, it was determined the facility failed to conduct weekly inspections of the emergency generator. The failed practice had the potential to affect the health and safety of patients, staff, and visitors because the reliability of the generator to provide emergency power to the facility in the event of the loss of normal power was not evaluated and could not be assured. The facility had a census of two patients on 06/27/12. The findings follow:

A Review of the Generator Run Log on 06/27/12 at 1305 revealed there was no documentation of weekly inspection of the generator.
B. In an interview on 06/27/12 at 1345, the Maintenance Director weekly inspections of the generator were not documented and there was no further documentation available for review.

Based on Disaster Manual review and interview, it was determined the written facility fire plan did not provide for the rescue of patients, isolation of fire and smoke, evacuation of smoke compartments, or the extinguishment of fire by fire extinguishers. The failed practice had the potential to affect all patients, staff, and visitors because proper response to fire could not be assured without a detailed written plan. The facility had a census of two patients on 06/27/12. The findings follow:

A. Review of the "Code Red" fire plan located in the Disaster Manual on 06/27/12 at 1205 revealed the policy and procedure for fire response in the facility did not provide instruction for the following:
1) The rescue of patients or individuals
2) The containment of fire and smoke
3) Evacuation of smoke of the immediate area and smoke compartment
4) The extinguishment of fire by the use of fire extinguishers.
B. In an interview on 06/28/12 at 1000 the Plant Services Director verified the fire plan did not address the specific actions required to be taken in the event of a fire emergency.

Reference NFPA 101 (2000 ed) Section 18.7.2.2

Based on Fire Alarm System inspection documentation review and interview, it was determined the facility failed to ensure the fire alarm system was inspected annually. The failed practice had the potential to affect the health and safety of patients, staff, and visitors because the reliability of the fire alarm system devices to alert building occupants and the fire department of a fire emergency was not assured. The facility had a census of two patients on 06/27/12. The findings follow:

A. Review of the Fire Alarm System inspection reports on 06/27/12 at 1315 revealed the most recent annual inspection of the fire alarm system occurred on 01/20/11.
B. In an interview on 06/27/12 at 1330, the Maintenance Director verified there was no further documentation available for review.

Based on interview, it was determined the facility failed to conduct weekly inspections of the emergency generator. The failed practice had the potential to affect the health and safety of patients, staff, and visitors because the reliability of the generator to provide emergency power to the facility in the event of the loss of normal power was not evaluated and could not be assured. The facility had a census of two patients on 06/27/12. The findings follow:

A Review of the Generator Run Log on 06/27/12 at 1305 revealed there was no documentation of weekly inspection of the generator.
B. In an interview on 06/27/12 at 1345, the Maintenance Director weekly inspections of the generator were not documented and there was no further documentation available for review.