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Based on observation and interview the facility failed to ensure illumination at exit discharge was arranged in accordance with NFPA 101, 2012 Edition, Chapter 7.8 and Chapter 19.2.8 as required.

Findings:

On 05/23/19 at 1:40 pm two designated exit discharges from the outpatient facility with the address of 211 were observed to have lighting fixtures on normal power with no battery backed up emergency lighting.

On 05/23/19 at 1:40 pm the surveyor asked Staff A if the existing lighting fixtures at the two exit discharges were on generator power and he stated no. The surveyor stated to be in compliance there either needs to be battery backed emergency powered lighting or lighting that is wired to the emergency generator at the two exit discharges. The surveyor asked Staff A if the outpatient building operates under the same CMS CNN as the main hospital and he stated yes.

Based on record review and interview, the facility failed to include the transmission of a fire alarm signal on each fire drill.

Findings:

Record review showed the fire drills for 2017 and 2018 did not document transmission of a fire alarm signal.

On 05/22/19 at approximately 3:37 pm the surveyor stated to Staff A the facility fire alarm drills should include documentation there was a transmission of a fire alarm signal for each fire drill. Staff A stated they would add that to the fire drill documentation.

Based on record review and interview the facility failed to ensure the building system risk assessments were completed.

Findings:

Record review showed the facility EES (Essential Electrical System) and Medical Gas building system risk assessments were not completed.

On 05/22/19 at 3:23 pm the surveyor asked Staff A for the EES and Medical Gas building system risk assessments and Staff A stated he was not aware of the requirement. Staff A stated they will get the medical gas and EES building system risk assessments started and completed.