HospitalInspections.org

Based on observation and interview the facility failed to ensure that the 2-hour rated building separation between the Hospital and the Ambulance Garage was maintained in accordance with the requirements of NFPA 101 - 2012 edition, Section 21.1.1.4, 21.1.1.4.1.1, 8.3, 8.3.4, 8.3.5 and 8.3.5.1. This deficient practice could affect all of the potential four inpatients, as well as an indeterminable number of outpatients, staff, and visitors, if a fire or smoke was allowed to spread through the 2-hour rated fire wall.

Findings include:

1. On 11/14/16 at 4:25pm observation revealed that 90-minute rated door in the 2-hour rated wall in room 907 was blocked open with concrete block and the door was unable to self-closing due to the concrete block.

2. On 11/15/16 at 2:17pm, observation revealed that the east door of the fire rated double doors to the ambulance garage did not automatically positive latch when tested three out of three times.

3. On 11/15/16 at 2:19pm, observation revealed that above the double doors to the 2-hour rated wall at the ambulance garage there was a penetration of an insulated pipe that was not properly firestopped.

4. On 11/15/16 at 2:26pm, observation revealed that above the ceiling at the 2-hour rated building separation between the pharmacy and the pharmacy stair there were penetrations of five conduits, a pipe, an insulated pipe and 2" by 3" gaps at the top of the wall at the corrugated metal deck that were not properly firestopped.

5. On 11/15/16 at 2:28pm, observation revealed that above the ceiling at the 2-hour rated wall above the door to the west door to the pharmacy the 2" by 3" gaps at the top of the wall at the corrugated metal deck were filled with fiberglass insulation and were not properly firestopped.

6. On 11/15/16 at 2:34pm, observation revealed that above the ceiling at the 2-hour rated wall above the double doors by room 2315 there were penetrations of a pipe, five conduits and two bundles of two to six cables that were not properly firestopped.

7. On 11/15/16 at 2:40pm, observation revealed that above the ceiling at the west portion of the 2-hour rated wall by medical records room 2501 there were exposed metal studs with drywall on one side only and a portion of the wall was shaft wall construction and the metal support channel on the shaft was was unprotected and exposed. These wall configurations do not have a 2-hour fire resistance rating. In addition, there was a penetration of a bundle of two to four cables that was not properly firestopped.

8. On 11/15/16 at 2:46pm, observation revealed that above the ceiling at the north portion of the 2-hour rated wall by medical records room 2501 there were exposed metal studs with drywall on one side only and a portion of the wall was shaft wall construction and the metal support channel on the shaft was was unprotected and exposed. These wall configurations do not have a 2-hour fire resistance rating. In addition, there was a 2" hole with a cable penetration and a penetration of two insulated pipes that were not properly firestopped.

9. On 11/15/16 at 2:47pm, observation revealed that above the ceiling at the 2-hour rated wall at the corner by the entry to the lab there was a 4" by 6" gap in the wall at the top of the wall.

10. On 11/15/16 at 2:52pm, observation revealed that above the ceiling at the 2-hour rated wall by the door to the Radiology Wing there was a 2" by 3" hole and a cable penetration that were not properly firestopped.

11. On 11/16/16 at 9:15am, observation revealed that above the ceiling at the 2-hour rated wall in the lab there were penetrations of two flexible metal conduits and a hole penetrated by two to four cables that were not properly firestopped.

These findings were confirmed by the Maintenance Supervisor and the Indian Health Services Facility Engineer Consultant - Bemidji office at the time of discovery.

Based on observation and interview the facility failed to ensure that the 2-hour rated building separation between the Radiology Wing and the modular storage building was maintained in accordance with the requirements of NFPA 101 - 2012 edition, Section 21.1.1.4, 21.1.1.4.1.1, 8.3 and 8.3.5. This deficient practice could affect an indeterminable number of outpatients, staff, and visitors, if a fire or smoke was allowed to spread through the 2-hour rated fire wall.

Findings include:

On 11/15/16 at 3:08pm observation revealed that above the ceiling at the 2-hour rated wall between the Radiology Wing and the modular storage building there were penetrations of five conduits and a bundle of two to six cables that were not properly firestopped.

This finding was confirmed by the Maintenance Supervisor and the Indian Health Services Facility Engineer Consultant - Bemidji office at the time of discovery.

Based on observation and interview the facility failed to ensure that exit access corridors were maintain free of any obstructions in accordance with the requirements of NFPA 101 - 2012 edition, Section 21.2, 21.2.1 and 7.1.10.1. This deficient practice could affect an indeterminable number of outpatients, staff, and visitors, if a fire or smoke was allowed to spread from the patient rooms to the exit access corridor or other spaces.

On 11/15/16 at 2:55pm, observation revealed that there was a horizontal sliding metal security gate located in the exit access corridor leading to the south exit from the Radiology Wing that obstructs the exit access when it is closed.

This finding was confirmed by the Maintenance Supervisor and the Indian Health Services Facility Engineer Consultant - Bemidji office at the time of discovery.

Based on observation and interview the facility failed to ensure the proper enclosure of enclosed stairs in accordance with the requirements of NFPA 101 - 2012 edition, Section 39,2,2,3, 39.3, 7.2.2, 7.2.2.5.1, 7.1.3.2, 7.1.3.2.1, 8.2 and 8.3.1.1. This deficient practice could affect an indeterminable number of outpatients, staff, and visitors, if a fire or smoke was allowed to spread through the stair enclosures.

Findings include:

1. On 11/16/16 at 10:13am, observation revealed that at the southeast stair the doors on the upper and lower levels only had a 20 minute fire resistance rating.

2. On 11/16/16 at 10:22am, observation revealed that on the lower level the door to Stair 1 had a window and a portion of the wood frame holding the window in place was missing.

These findings were confirmed by the Maintenance Supervisor and the Indian Health Services Facility Engineer Consultant - Bemidji office at the time of discovery.

Based on observation and interview the facility failed to maintain rated exit stair enclosure in accordance with the requirements of NFPA 101 - 2012 edition, sections 19.2, 19.2.1, 19.2.2.3, 7.2.2.5, 7.1.3.2.1 and 7.1.3.2.1(9) . This deficient practice could affect all of the potential four inpatients, an indeterminable number of outpatients, staff, and visitors, if the exit stair was compromised by an event happening in an unoccupied room that opened directly onto the rated exit stair enclosure.

Findings include:

1. On 11/15/16 at 9:30am observation revealed that on the lower level the boiler room, elevator machine room and a toilet room opened directly onto the rated stair enclosure.

2. On 11/15/16 at 1:02pm, observation revealed that on the upper level storage closet 425, a vacant office, the IT storage room 426A, the loading dock soiled linen room and room 418 opened directly onto the rated exit stair enclosure.

These findings were confirmed by the Maintenance Supervisor and the Indian Health Services Facility Engineer Consultant - Bemidji office at the time of discovery.

Based on observation and interview the facility failed to exit signage to mark the means of egress in accordance with the requirements of NFPA 101 - 2012 edition, section 21.2.10 and 7.10. This deficient practice could affect an indeterminable number of outpatients, staff, and visitors, if the occupants were unclear on how to exit the building in the event of a fire.

Finding include:

On 11/15/16 at 2:53pm, observation revealed that there was no exit sign above the south door from the Radiology wing and the way to an exit was not readily obvious.

This finding was confirmed by the Maintenance Supervisor and the Indian Health Services Facility Engineer Consultant - Bemidji office at the time of discovery.

Based on observation, record review and interview the facility failed to ensure that vertical openings were properly enclosed as required by NFPA 101 - 2012 edition, Section 39.3.1, 39.3.1.1, 39.5.2, 9.2, 9.2.1, 8.3 8.6, 8.6.2, 8.6.4, 8.6.4.3 and 8.6.5; as well as, NFPA 90A 2012 edition sections 5.3.4, , 5.3.4.1, 5.3.4.1, 5.3.4.6, 5.4 and 5.4.1.1 This deficient practice could affect an indeterminable number of outpatients, staff, and visitors, if a fire or smoke was allowed to spread throught the floors via the shaft wall construction.

Findings include:

1. On 11/16/16 at 9:25am observation revealed that at the shaft in room 2141 there was a 1/2" gap around the metal stud penetration of the shaft wall that was not properly fire stopped.

2. On 11/16/16 at 9:30am, observation revealed at at the shaft in the pharmacy office there was a 1/2" gap around the duct penetration that was not properly firestopped and there was no fire damper where the duct penetrated the shaft wall.

3. On 11/16/16 at 9:31am, observation revealed that at the shaft in room 2138 there was a 1/4" gap in the drywall and the rated shaft stopped at an unprotected steel beam that did not have a fire resistance rating.

4. On 11/16/16 at 9:33am, observation revealed that the shaft in room 2141 stopped at the bottom of an unprotected steel beam that did not have a fire resistance rating.

5. On 11/16/16 at 9:36am, observation revealed that above the ceiling at the shaft by the nurse's team area there were penetrations of a 3" pipe and an insulated pipe that were not properly firestopped. The shaft wall stopped at an unprotected steel beam that did not have a fire resistance rating.

6. On 11/16/16 at 9:37am observation revealed that the two shaft on the east side of the building penetrated the mechanical room floor and the floor between the upper and lower levels and there were no fire dampers at any of the duct penetrations in the rated shaft wall. At 10:30am, review of the architectural plan sheet M301 dated 1/17/14 prepared by EAPC Architects showed that on the upper level there were six duct penetrations of the rated shaft wall and none had fire dampers.

7. On 11/16/16 at 10:05am, observation revealed that on the lower level the northeast shaft opens into the electrical room and the electrical room door did not have a fire resistance rating.

8. On 11/16/16 at 10:07am, observation revealed that the two east shafts opened to the space above the lay-in ceiling tile and were not separated from this floor by fire rated construction.

9. On 11/16/16 at 10:10am, observation revealed that in data room 1149 the shaft opened into the room and was not separated by fire rated construction.

10. On 11/16/16 at 10:19am, observation revealed that above the ceiling outside of room 1105 the pipe penetration in the floor was sealed with expandable foam and was not properly firestopped.

These findings were confirmed by the Maintenance Supervisor and the Indian Health Services Facility Engineer Consultant - Bemidji office at the time of discovery.

Based on observation and interview the facility failed to maintain the the protection of hazardous rooms in accordance with the requirements of NFPA 101 - 2012 edition, section 19.3.2.1 and 19.3.2.1.3. These deficient practices could affect all of the potential four inpatients, as well as an indeterminable number of outpatients, staff, and visitors, if a fire occurred in a hazardous room and was not contained in the room.

Findings include:

1. On 11/15/16 at 1:03pm observation revealed that the loading dock soiled linen room 421 door did not self-close completely when tested three out of three times.

2. On 11/15/16 at 1:23pm, observation revealed that the door to storage room 429 did not self-close completely when tested three out of three times.

These findings were confirmed by the Maintenance Supervisor and the Indian Health Services Facility Engineer Consultant - Bemidji office at the time of discovery.

Based on observation and interview the facility failed to install smoke detection in accordance with the requirements of NFPA 101 - 2012 edition, sections 4.6.12.1 and 4.6.12.3 and NFPA 72 - 2010 edition, sections 10.14.3.1 and 17.7.4.1. These deficient practices could affect an indeterminable number of outpatients, staff, and visitors, if the activation of the fire alarm system were delayed.

Findings include:

1. On 11/16/16 at 10:44am, observation revealed that at the Dental Clinic east entry hallway the smoke detector was located within the air flow of the adjacent air supply outlet.
2. On 11/16/16 at 10:45am, observation revealed that the smoke detector in the Dental Clinic bay 6 was located within the air flow of the adjacent air supply outlet.

These findings were confirmed by the Maintenance Supervisor and the Indian Health Services Facility Engineer Consultant - Bemidji office at the time of discovery.

Based on observation and interview the facility failed to install smoke detection in accordance with the requirements of NFPA 101 - 2012 edition, sections 4.6.12.1 and 4.6.12.3 and NFPA 72 - 2010 edition, sections 10.14.3.1 and 17.7.4.1. This deficient practice could affect all of the potential four inpatients, an indeterminable number of outpatients, staff, and visitors, if the activation of the fire alarm system were delayed.

Findings include:

1. On 11/15/16 at 1:05pm, observation revealed that the smoke detector in the corridor by room 431 was located within the air flow of the adjacent air supply outlet.

2. On 11/15/16 at 1:59pm, observation revealed that the smoke detector in the corridor by room 316 was located within the air flow of the adjacent air supply outlet.

These findings were confirmed by the Maintenance Supervisor and the Indian Health Services Facility Engineer Consultant - Bemidji office at the time of discovery.

Based on record review and interview the facility failed to test the fire alarm system in accordance with the requirements of NFPA 101 - 2012 edition, Sections 4.6.12.3, 19.3.4, 9.6 and NFPA 72 - 2010 edition sections 14.4, 14.4.5 and Table 14.4.5 . This deficient practice could affect all of the potential four inpatients, as well as an indeterminable number of outpatients, staff, and visitors, if a fire alarm system did not function properly in the event of a fire.

Findings include:

On 11/15/16 at 10:55am, review of the document titled "Inspection and Testing Form" dated 9/19/16 and an interview with the Maintenance supervisor revealed that the facility did not conduct a quarterly test of the off-premises transmission equipment.

Based on record review and interview the facility failed to test the fire alarm system in accordance with the requirements of NFPA 101 - 2012 edition, Sections 4.6.12.3, 21.3.4, 9.6 and NFPA 72 - 2010 edition sections 14.4, 14.4.5 and Table 14.4.5 . This deficient practice could affect all of the potential four inpatients, as well as an indeterminable number of outpatients, staff, and visitors, if a fire alarm system did not function properly in the event of a fire.

Findings include:

On 11/15/16 at 10:55am, review of the document titled "Inspection and Testing Form" dated 9/19/16 and an interview with the Maintenance supervisor revealed that the facility did not conduct a quarterly test of the off-premises transmission equipment.

Based on record review and interview the facility failed to test the fire alarm system in accordance with the requirements of NFPA 101 - 2012 edition, Sections 4.6.12.3, 9.6 and NFPA 72 - 2010 edition sections 14.4, 14.4.5 and Table 14.4.5 . This deficient practice could affect all of the potential four inpatients, as well as an indeterminable number of outpatients, staff, and visitors, if a fire alarm system did not function properly in the event of a fire.

Findings include:

On 11/15/16 at 10:55am, review of the document titled "Inspection and Testing Form" dated 9/19/16 and an interview with the Maintenance Supervisor revealed that the facility did not conduct a quarterly test of the off-premises transmission equipment.

Based on observation and interview the facility failed to ensure that a complete sprinkler system was installed in accordance with the requirements of NFPA 101 - 2012 edition, Section 4.6.12.3 and NFPA 13 - 2010 edition sections 8.1 and 8.1.1. This deficient practice could affect an indeterminable number of outpatients, staff, and visitors, if a fire or smoke was allowed to spread due to missing sprinkler protection.

Findings include:

1. On 11/16/16 at 10:02am, observation revealed that the elevator machine room was not sprinklered.

2. On 11/16/16 at 10:02am, an interview with the Maintenance Supervisor revealed that it could not be confirmed that the elevator pit was protected by sprinklers.

These findings were confirmed by the Maintenance Supervisor and the Indian Health Services Facility Engineer Consultant - Bemidji office at the time of discovery.

Based on observation and interview the facility failed to maintain the sprinkler system in accordance with the requirements of NFPA 101 - 2012 edition, sections 4.6.12.1 and 4.6.12.3; NFPA 13 - 2010 edition section 8.6.6.1; as well as, NFPA 25 - 2011 edition, sections 5.2, 5.2.1, 5.2.1.1, 5.2.1.1.1, 5.3.2 and 5.3.3.1. These deficient practices could affect an indeterminable number of outpatients, staff, and visitors, if the activation of the sprinkler system were delayed.


Findings include:

1. On 11/15/16 at 9:15am, observation revealed that the two fire department connections located on the south side of the building were not identified with signage.
2. On 11/15/16 at 11:08am, review of the document titled " Absolute Fire Protection, Inspection, Testing, and Maintenance of Wet Pipe Sprinkler Systems " dated 7/21/16 and an interview with the Maintenance Supervisor revealed that quarterly waterflow tests were not conducted on the sprinkler system.
3. On 11/15/16 at 4:30pm, observation revealed that one gauge on the sprinkler system had a 1973 date and the second gauge did not have a date. The facility had no documentation that the gauges had been recalibrated or replaced within the last five years.

These findings were confirmed by the Maintenance Supervisor and the Indian Health Services Facility Engineer Consultant - Bemidji office at the time of discovery.

Based on observation, record reveiw and interview the facility failed to maintain the sprinkler system in accordance with the requirements of NFPA 101 - 2012 edition, section 19.3.5.3; NFPA 13 - 2010 edition section 8.6.6.1; as well as, NFPA 25 - 2011 edition, sections 5.2, 5.2.1, 5.2.1.1, 5.2.1.1.1, 5.3.2 and 5.3.3.1. These deficient practices could affect all of the potential four inpatients, as well as an indeterminable number of outpatients, staff, and visitors, if the activation of the sprinkler system were delayed.


Findings include:

1. On 11/14/16 at 4:00pm, observation revealed that in room 308 there was a 1 " gap in the ceiling adjacent to the sprinkler.
2. On 11/15/16 at 9:15am, observation revealed that the two fire department connections located on the south side of the building were not identified with signage.
3. On 11/15/16 at 11:08am, review of the document titled " Absolute Fire Protection, Inspection, Testing, and Maintenance of Wet Pipe Sprinkler Systems " dated 7/21/16 and an interview with the Maintenance Supervisor revealed that quarterly waterflow tests were not conducted on the sprinkler system.
4. On 11/15/16 at 1:20pm, observation revealed that in room 431 the east sprinklers in the room were obstructed by storage cabinets located within 2.5 " of the sprinklers.
5. On 11/15/16 at 2:21pm, observation revealed that in the ambulance storage room the sprinkler was obstructed by the storage of boxes that were located 4 " from the sprinkler.
6. On 11/15/16 at 4:30pm, observation revealed that one gauge on the sprinkler system had a 1973 date and the second gauge did not have a date. The facility had no documentation that the gauges had been recalibrated or replaced within the last five years.

These findings were confirmed by the Maintenance Supervisor and the Indian Health Services Facility Engineer Consultant - Bemidji office at the time of discovery.

Based on observation, record review and interview the facility failed to maintain the sprinkler system in accordance with the requirements of NFPA 101 - 2012 edition, sections 4.6.12.1 and 4.6.12.3; NFPA 13 - 2010 edition section 8.6.6.1; as well as, NFPA 25 - 2011 edition, sections 5.2, 5.2.1, 5.2.1.1, 5.2.1.1.1, 5.3.2 and 5.3.3.1. These deficient practices could affect an indeterminable number of outpatients, staff, and visitors, if the activation of the sprinkler system were delayed.


Findings include:

1. On 11/15/16 at 9:15am, observation revealed that the two fire department connections located on the south side of the building were not identified with signage.
2. On 11/15/16 at 11:08am, review of the document titled " Absolute Fire Protection, Inspection, Testing, and Maintenance of Wet Pipe Sprinkler Systems " dated 7/21/16 and an interview with the Maintenance Supervisor revealed that quarterly waterflow tests were not conducted on the sprinkler system.
3. On 11/15/16 at 4:30pm, observation revealed that one gauge on the sprinkler system had a 1973 date and the second gauge did not have a date. The facility had no documentation that the gauges had been recalibrated or replaced within the last five years.

These findings were confirmed by the Maintenance Supervisor and the Indian Health Services Facility Engineer Consultant - Bemidji office at the time of discovery.

Based on observation, record review and interview the facility failed to maintain the sprinkler system in accordance with the requirements of NFPA 101 - 2012 edition, sections 4.6.12.1 and 4.6.12.3; NFPA 13 - 2010 edition section 8.6.6.1; as well as, NFPA 25 - 2011 edition, sections 5.2, 5.2.1, 5.2.1.1, 5.2.1.1.1, 5.3.2 and 5.3.3.1. These deficient practices could affect an indeterminable number of outpatients, staff, and visitors, if the activation of the sprinkler system were delayed.


Findings include:

1. On 11/15/16 at 9:15am, observation revealed that the two fire department connections located on the south side of the building were not identified with signage.
2. On 11/15/16 at 11:08am, review of the document titled " Absolute Fire Protection, Inspection, Testing, and Maintenance of Wet Pipe Sprinkler Systems " dated 7/21/16 and an interview with the Maintenance Supervisor revealed that quarterly waterflow tests were not conducted on the sprinkler system.
3. On 11/15/16 at 4:30pm, observation revealed that one gauge on the sprinkler system had a 1973 date and the second gauge did not have a date. The facility had no documentation that the gauges had been recalibrated or replaced within the last five years.
4. On 11/16/16 at 10:46 am, observation revealed that the sprinklers in rooms 219 and 220 were loaded with a grey fuzzy substance.
5. On 11/16/16 at 10:59 am, observation revealed that the sprinkler rooms 124 had paint on it.

These findings were confirmed by the Maintenance Supervisor and the Indian Health Services Facility Engineer Consultant - Bemidji office at the time of discovery.

Based on observation and interview the facility failed to install fire extinguishers in accordance with the requirements of NFPA 101 - 2012 edition, section 19.3.5.12 and NFPA 10 - 2010 edition sections 6.1.3.8, 6.1.3.8.1 and 6.1.3.8.3. These deficient practices could affect all of the potential four inpatients, as well as an indeterminable number of outpatients, staff, and visitors, if there was a delay in the use of a fire extinguisher due to its improper installation.

Finding Include:

1. On 11/15/16 at 1:21pm, observation revealed that the fire extinguisher located in Clinical Engineering room 431 was mounted on the wall so that the top the extinguisher was located 5'-9" above the floor.

2. On 11/15/16 at 3:40pm, observation revealed that the fire extinguisher in the Hospital elevator machine room was sitting on the floor and not mounted so that the bottom was at least 4" above the floor.

These findings were confirmed by the Maintenance Supervisor and the Indian Health Services Facility Engineer Consultant - Bemidji office at the time of discovery.

Based on observation and interview the facility failed to install and maintain corridor doors in accordance with the requirements of NFPA 101 - 2012 edition, sections 19.3.6.3, 19.3.6.3.1 and 19.3.6.3.5. This deficient practice could affect all of the potential four inpatients, an indeterminable number of outpatients, staff, and visitors, if the corridor doors did not remain closed in the event of a fire.

Findings include:

1. On 11/15/16 at 1:24pm, observation revealed that the corridor door to the employee dining room did not have a latch and was not automatically positive latching.

2. On 11/15/16 at 2:08pm, observation revealed that the corridor doors to the emergency room were sliding glass doors and there not automatically positive latching.

3. On 11/15/16 at 2:13pm, observation revealed that the corridor door to the Emergency Medical Services suite did not have a latch and was not automatically positive latching.

These findings were confirmed by the Maintenance Supervisor and the Indian Health Services Facility Engineer Consultant - Bemidji office at the time of discovery.

Based on observation and interview the facility failed to ensure that the smoke barrier walls were maintained in accordance with the requirements of NFPA 101 - 2012 edition, Sections 4.6.12.3, 19.3.7, 19.3.7.3, 8.5, 8.5.2 and 8.5.6 . This deficient practice could affect all of the potential four inpatients, as well as an indeterminable number of outpatients, staff, and visitors, if a fire or smoke was allowed to spread from one smoke compartment to another.

Findings include:

1. On 11/15/16 at 1:30pm, observation revealed that at the smoke barrier in room 418 there was a 2" gap in the wall and two metal sleeves penetrated by 40-60 cables and a 6" by 14" gap in the wall penetrated by two gray pipes that were not properly firestopped.

2. On 11/15/16 at 1:37pm, observation revealed that above the ceiling at the smoke barrier wall in room 411 there were penetrations of a duct, a pipe, a conduit, a bundle of two to 10 cables and a 1/4" by 20" gap in the wall that were all sealed with expandable foam and were not properly firestopped.

3. On 11/15/16 at 1:47pm, observation revealed that above the ceiling at the smoke barrier in the bathroom of room 413 there were penetrations of four conduits sealed with fiberglass and a 2" hole above the duct that were not properly firestopped.

These findings were confirmed by the Maintenance Supervisor and the Indian Health Services Facility Engineer Consultant - Bemidji office at the time of discovery.

Based on record review and and interview the facility failed to have a written fire safety plan that addressed all of the items required by NFPA 101 - 2012 edition, Section 21.7.2.2. This deficient practice could affect all of the potential four inpatients, as well as an indeterminable number of outpatients, staff, and visitors, if staff did not respond appropriately in the event of a fire.

Findings include:

On 11/15/16 at 10:05am, review of the document titled "Fire Prevention Management Plan" dated 7/25/16 revealed that the facility's written fire safety plan did not address, transmission of the fire alarm to the fire department, emergency phone call to the fire department or evacuation of the smoke compartment.

This finding was confirmed by the Maintenance Supervisor and the Indian Health Services Facility Engineer Consultant - Bemidji office at the time of discovery.

Based on record review and interview the facility failed to have a written fire safety plan that addressed all of the items required by NFPA 101 - 2012 edition, Section 19.7.2.2. This deficient practice could affect all of the potential four inpatients, as well as an indeterminable number of outpatients, staff, and visitors, if staff did not respond appropriately in the event of a fire.

Findings include:

On 11/15/16 at 10:05am, review of the document titled "Fire Prevention Management Plan" dated 7/25/16 revealed that the facility's written fire safety plan did not address, transmission of the fire alarm to the fire department, emergency phone call to the fire department or evacuation of the smoke compartment.

This finding was confirmed by the Maintenance Supervisor and the Indian Health Services Facility Engineer Consultant - Bemidji office at the time of discovery.

Based on record review and and interview the facility failed to conduct fire drills in accordance with the requirements of NFPA 101 - 2012 edition, Section 4.7.1, 4.7.2, 4.7.6, 19.7.1, 19.7.1.4 and 19.7.1.6. This deficient practice could affect all of the potential four inpatients, as well as an indeterminable number of outpatients, staff, and visitors, if staff did not respond appropriately in the event of a fire.

Findings include:

1. On 11/15/16 at 10:40am, review of the documents titled "Fire Drill Report" for the last 12 months revealed that transmission of the fire alarm signal was not documented on the reports.

2. On 11/15/16 at 10:41am, review of the documents titled "Fire Drill Report" for the last 12 months revealed that fire drills were not conducted at varied times. Five of five fire drills on the night shift were conducted between 5:30am and 6:30am.

3. On 11/15/16 at 10:42am, review of the documents titled, "Fire Drill Report: for the last 12 months revealed that there was no fire drill conducted on the night shift during the fourth quarter of 2015 or 2016.

These findings were confirmed by the Maintenance Supervisor and the Indian Health Services Facility Engineer Consultant - Bemidji office at the time of discovery.

Based on record review and interview the facility failed to conduct fire drills in accordance with the requirements of NFPA 101 - 2012 edition, Section 4.7.1, 4.7.2, 4.7.6, 21.7.1, 21.7.1.4 and 21.7.1.6. This deficient practice could affect all of the potential four inpatients, as well as an indeterminable number of outpatients, staff, and visitors, if staff did not respond approprately in the event of a fire.

Findings include:

1. On 11/15/16 at 10:40am, review of the documents titled "Fire Drill Report" for the last 12 months revealed the transmission of the fire alarm signal was not documented on the report forms.


2. On 11/15/16 at 10:41am, review of the documents titled "Fire Drill Report" for the last 12 month revealed that fire drills were not conducted at varied times. Five of five fire drills on the night shift were conducted between 5:30am and 6:30am.

3. On 11/15/16 at 10:42am, review of the documents titled, "Fire Drill Report" for the last 12 months revealed that there was no fire drill conducted on the night shift during the fourth quarter of 2015 or 2016.

These findings were confirmed by the Maintenance Supervisor and the Indian Health Services Facility Engineer Consultant - Bemidji office at the time of discovery.

Based on observation and interview the facility failed to ensure that the drapery material in the facility met the requirements of NFPA 101 - 2012 edition, Section 19.7.5.1. This deficient practice could affect all of the potential four inpatients, as well as an indeterminable number of outpatients, staff, and visitors, if a fire or smoke was allowed to spread from the patient rooms to the exit access corridor or other spaces.

Findings include:

On 11/15/16 at 1:40pm, observation revealed that there were fabric draperies in patient rooms 404, 412 and 413. The draperies had no label indicating they were fire retardant or meet NFPA 701 and the facility had no documentation on the fire retardant nature of the material.

This finding was confirmed by the Maintenance Supervisor and the Indian Health Services Facility Engineer Consultant - Bemidji office at the time of discovery.

Based on observation and interview the facility failed to ensure that the electrical system was installed in accordance with the requirements of NFPA 101 - 2012 edition, Section 19.5.1, 9.1, 9.1.2 and NFPA 70 - 2010 edition, The National Electrical Code. This deficient practice could affect all of the potential four inpatients, as well as an indeterminable number of outpatients, staff, and visitors, if incorrectly installed electrical system initiated a fire.

Findings include:

On 11/15/16 at 2:35pm observation revealed that above the ceiling at the double doors by room 2315 there were exposed electrical wires outside of a junction box.

This finding was confirmed by the Maintenance Supervisor and the Indian Health Services Facility Engineer Consultant - Bemidji office at the time of discovery.