HospitalInspections.org

REMAINS CITED

Based on observations, staff interviews, and review of facility design drawings and documentation, the facility failed to correct the trash and linen chutes access rooms to ensure they were located in a one hour fire resistant rated protected area. This affected chutes on the first, second, third, and fourth floors of the facility. This has the potential to affect all those utilizing these areas of the facility. The patient census during this visit was 168.

Findings include:

A tour was conducted in the facility on 05/15/12 , between 1:07 PM and 3:00 PM, with Staff A (Maintenance), Staff B (Manager of Maintenance), Staff C (Director of Facilities Management Services), and Staff D (Coordinator of Environment of Care/Construction). During this tour observations of the trash and linen chute access rooms on floors one through four, revealed there were no construction changes evident in these areas since the 03/30/12 Life Safety Code survey visit, with the exception of fire extinguishers were now located in each area. This was verified with Staff C during the tour, who stated the facility required extra time in order to complete the construction.

At the time of this visit, Staff C provided documented evidence, based on their plan of correction, of the following that has been completed (related to construction of the one hour fire resistant rated protected areas for trash and linen chutes):
a) design drawings to enclose the linen and trash chute openings on floors one, two, three, and four,
b) correspondence with the construction company hired to complete the work,
c) An insurance company Underwriting Risk Assessment Report, dated 04/04/12, which discussed linen chute collection areas on each floor, which was determined by the insurance company to be an acceptable arrangement for property insurance purposes,
d) A letter, dated 04/01/12, by the Local Fire Marshal of the facility's governing city, approving temporary portable ABC Fire Extinguishers installed in each chute access room.
e) An interim Life Safety Plan for additional fire extinguishers being placed in each chute room on each floor 1,2,3, and 4, and
f) Documentation of available funding to finance the construction of these access rooms.

An interview with Staff C, on 05/15/12, at 12:50 PM, and on 05/16/12, at 8:30 AM, revealed the facility requested an extension on their plan of correction for the 03/30/12 Life Safety Code survey in regards to K 71, in order to complete construction of these chute access rooms. This employee stated the facility still requires additional time in order to complete the construction.




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