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Based on observations made during the Follow Up survey for life safety from fire on 11/12/15 with the physical environment department supervisor (employee #5), it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in an emergency are provided in some areas of the Pharmacy, Pharmacy storage at the policlinic Castañer and Intravenous fluid storage at the hospital. In nursing station of the observation area of the emergency department an emergency light sort out with black tape and one emergency lamp of the Policlinic between medical offices did not work. The facility failed to ensure that tests are performed on the emergency lighting system as required by the 2010 edition of Life Safety Code of the NFPA 7.9.3.

Findings include: Deficiency Not corrected

1. The facility lacks emergency lighting (battery operated lamps) for a period of 90 minutes as determined by the observational tour from 9/22/15 through 9/23/15 from 9:55 am until 3:00 pm in the following areas:
a. Intravenous fluid storage.
b. Pharmacy at the Policlinic
c. Pharmacy storage at the Policlinic
(Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails as required since March of 2006).
2. Review of documentation on 9/23/15 at 9:00 am of tests to the emergency lighting system (battery operated lamps of 90 minutes duration) from the past twelve months provided evidence of monthly 30 second tests. However, functional tests conducted once a year for no less than 90 minutes was not found.

Based on observations, record review and interview made during the follow up survey for life safety from fire on 11/12/15, it was determined that the facility failed to ensure that the emergency room, other wards and the Policlinic have written plans for staff to follow with respect to their duties in the event of an emergency as required by the 2012 edition of the Life Safety Code of the NFPA Section 18.7.1.1.

Findings include: Deficiency Not Corrected

1. No evidence was found on 9/23/15 at 11:50 am that emergency room personnel have a plan or assignments with specific tasks in the event of an emergency related to extinguisher use, circuit breaker shut off and oxygen valve shut off. All emergency personnel must be instructed related to their assignments and periodically tested for its implementation and the assignment must be posted for review by staff.

2. Record review performed on 9/24/15 at 9:40 am until 11:00 am revealed that drills performed on 2014 the ER staff participates just in 2 drills. Surveyor asked on 9/22/15 to employee # 22 emergency room supervisor for the assignment of duties in case of a fire and it never present the program. On 9/23/15 at 9:30 am surveyor asked to employee # 22 evidence of the assignment of duties in the ER in case of fire. The program never was presented.

Based on life safety code follow up survey on 11/12/15, record reviewed and interview, it was determined that the facility failed to perform emergency and fire drills schedule. The deficient practice affected 1 out of 1 smoke compartment, staff and all patients.

Findings include: Deficiency Not corrected

1. During a review of the facility's fire drill reports and emergency drills for the year prior to the survey and current year on 09/24/ 15 at 11:20 a.m., the facility provide a documented fire drill for the first shift for the second and fourth quarter of 2014, 1drill for the second shift 3:00 pm third quarter of 2015. No schedule for emergency disaster or fire drills for 2014 and 2015 was found.

Interview with the Safety Officer (employee #4) on 09/23/15 at 3:20 p.m., stated " At this moment I do not have a schedule prepared to show you " .
Interview with the Facility Administrator (employee #21) on 09/24/15 at 10:20 am indicates that the safety officer it is practically new and his starting organizing the department in these months.
However record reviews performed on 09/24/15 at 10:30 am with the administrator (employee #21) reveals that the safety officer has all the training and requirements to perform the job.

Based on observations made during the follow up survey for life safety from fire on 11/12/15 with the facility's physical plant manager, it was determined that the facility failed to ensure that smoke detectors are available in required areas such as Policlinic (Pulmonary function office, Clinical record office and the reception , Pharmacy (office and the storage), Hospital( medicine ward supply storage, housekeeping storage, soil linen room) and that the facility's fire alarm automatically notifies an approved central station in accordance with the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code) which could affect 3 out of 3 admitted patients, staff and visitors.

Findings include: Deficiency Not corrected

1. Policlinic (Pulmonary function office, Clinical record office and the reception, Pharmacy (office and the storage), Hospital (medicine ward supply storage, housekeeping storage, soil linen room) were visited on 9/23/15 thru 9/24/2015 from 9:55 am until 3:00 pm and provided evidence that the mentioned before areas do not have smoke detectors connected to the fire alarm system.

2. The facility lacks a written contract as observed on 9/24/07 at 11:00 am to substantiate that the fire alarm system has an automatic annunciation to an approved central station.

3. The policlinic (Off site location) is an old building used before for manufacturing. At this moment the building is divided 23 areas with gypsum board partition. The facility has 7 fire extinguisher and 13 smoke detector operated with battery. The facility does not have fire alarm system with an automatic annunciation to an approved central station.

Interview with the administrator (employee #21) performed on 9/24/15 at 10:45 am reveals that the Policlinic does not has fire alarm system since the facility is operating. Employee #21 indicates that this facility is open about 10 years ago. However evidence of the Fire Department Endorsement was provided.

Based on the review of written documents related to the preventive maintenance of the fire alarm system and its components during the follow up survey for life safety from fire on 11/12/15 with the facility's Physical Plant Supervisor (employee #5) and Administrator (employee #21) and interviews, it was determined that the facility is not performing visual inspections, sensing chamber tests or battery tests to the fire alarm system in accordance with NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include: Defciciency Not corrected

1. Written evidence reviewed on 09/24/15 at 10:30 am with the facility's Physical Plant Manager (employee #5) and Administrator (employee #21) about the tests to the fire alarm system and its components indicates that the facility is not performing the following tests:

a. Visual inspections to the main control panel to verify trouble signals and check battery electrolyte level (monthly).

b. All smoke detectors must be tested in place to ensure smoke entry into sensing chamber and an alarm response which includes the smoke detectors in the air conditioner system (twice a year).

c. Ability of batteries to meet standby and alarm requirements shall be verified, corrosion and leakage, tightness of connections and battery terminals shall be cleaned (monthly).

d. Location of pull-down stations and tests (monthly).

e. Visible (strobe lights) and audible signal tests (monthly).

2. Interview with the administrator (employee #21) about the test to the fire alarm system and its component of the Policlinic and Pharmacy of Castañer facility (Off site location) reveals that the facility is not performing tests to the fire alarm because this building does not have fire alarm system.

3.The Policlinic and Pharmacy facility lacks of the following accordance to the NFPA 72 (National Fire Alarm Code) All smoke detectors must be tested in place to ensure smoke entry into sensing chamber and an alarm response which includes the smoke detectors in the air conditioner system (twice a year).

Based on the review of written documents related to the preventive maintenance of the smoke detectors with the physical plant supervisor (employee #5) during the follow up survey for life safety from fire on 11/12/15, it was determined that the facility is not testing and inspecting smoke detectors on a regular basis in accordance with LSC 2000 9.6.1.3 affecting 3 out of 3 admitted patient, staff and visitors.

Findings include: Deficiency Not corrected

Review of written documents related with smoke detector maintenance on 9/24/15 at 10:30 am provided evidence that the failed to test smoke detectors during twelve out of twelve months of 2014 and nine out of twelve months of 2015. The facility do not tests smoke detectors on a monthly basis, the facility failed to provide evidence of visual and audible inspections and testing. Failure to verify smoke detectors for three consecutive months could compromise the safety of its patients, staff and visitors.

Based on the review of written evidence performed during the follow up survey for Life safety from fireon 11/12/15 with the facility's physical plant supervisor (employee #5), it was determined that this facility does not comply with the required monthly maintenance documentation of the fire extinguishers as required by the 2000 edition of the Life Safety Code of the NFPA Section 9.7.4.1 and NFPA 10 which could affect 3 out of 3 admitted patients, staff and visitors.

Findings include: Deficiency Not corrected

Written evidence about the required monthly visual inspections and maintenance to the fire extinguishers was reviewed on 9/24/15 at 11:00 am and provided evidence that the facility has a contracted agency that performs annual fire extinguisher tests. However, a monthly inspection checklist that provides a permanent record must be kept on file that includes: date of inspection, initials of person performing inspection, proper location, if fully charged, hose and nozzle inspection, pin placement and if it is operable.

Based on observations during the follow up survey for Life safety from fire on 11/12/15 with the facility's Physical plant supervisor (employee #5), it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-R.

Findings include: Deficiency Not corrected

1 Staff assignments for all three shifts for all personnel were reviewed on 09/23/15 at 2:00 pm. The assignments provided evidence that staff is identified by personnel positions per shift and specific tasks to perform during an emergency. However, no evidence was found of specific assignments related to the switching off of electrical breakers or the shutting of the main oxygen valve. All nursing personnel must be instructed in the use and operation of the breaker panels and oxygen valves.


2. Standpipes (fire hoses) were observed during the life safety observational tour on 9/22/15 from 9:55 am till 3:00 pm and the following was determined:

a. No evidence was found of the documentation of the standpipe and Hose System Inspection, Testing and maintenance in accordance with NFPA 25 chapter 6 related with: control valves, pressure regulating devices, piping, hose connections, cabinet, hose, hose storage device, alarm device, hose nozzle, pressure control device, pressure reducing valve, hydrostatic test, flow test, main drain test, hose connections and valves (all types).

Based on observations and documents reviewed during the follow up survey for life safety from fire on 11/12/15 with the administrator (employee #21) and facility's physical plant supervisor (employee #5), it was determined that the facility failed to test electrical receptacles that are supplied by the essential electrical system at least twice a year and the annual test to the regularly supplied receptacles was performed sixteen months ago, which is not in accordance with NFPA 99 Section 7-6.2.1.2.

Findings include: Deficiency Not corrected

1. Written evidence was reviewed on 9/24/2015 at 11:20 am about preventive maintenance to the receptacles indicates that they are testing the receptacles supplied by the generator once a year. However, receptacles that are supplied by the essential electrical system (generator) supply power to critical care areas and equipment (cardiac monitors, life support equipment, and wet locations). Equipment or wiring faults can cause abnormal temperature increases, these abnormal temperatures may cause fire and explosions. Critical care areas, wet locations and areas where critical care equipment are plugged into the essential electrical receptacles are required to be tested in intervals not exceeding six months because even brief interruptions of power can cause malfunctions of some equipment and appliances.

2. Written evidence was reviewed on 9/23/15 at 2:40 pm about preventive maintenance to the receptacles indicates that they are testing the receptacles supplied by the generator once a year. No evidence was provided about facility testing the receptacles.