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Based on observation and staff interview, the facility failed to ensure fire alarm control functions were protected in accordance with NFPA 101 - 2012 Edition Sections: 19.3.4.4 and 9.6.1.8.1. This deficient practice had the potential to affect all patients receiving services from the facility.

Findings include:

Observation on 12/10/19 during facility tour between 7:45 A.M. and 11:45 A.M. with Staff E and Staff F revealed fire alarm control units not protected according to applicable code. At 8:00 A.M. in a second floor labeled "I.D.F." was a fire alarm control function panel not protected with a smoke detector in the room. The room was not occupied during facility tour.

Interview with Staff E and Staff F at time of discovery during tour verified the deficient practice.

Based on record review, and staff interview, the facility failed to ensure a Fire Watch Policy was developed in accordance with NFPA 101 - 2012 Edition 9.6.1.6. This deficient practice had the potential to affect all patients receiving services from the facility.

Findings include:

Record review on 12/09/19 between 12:45 P.M. to 4:30 P.M. revealed no Fire Watch Procedure was available for review. A copy of the facility fire watch policy was requested at entrance conference with Staff E and Staff F. The document provided for review for the fire watch procedures did not address that if the fire alarm system was out of service for four hours or more that the building would be evacuated, or a fire watch initiated. It did not address the assigning of individuals to conduct a fire watch as their sole duties. This document also did not indicate that when a fire watch would be initiated the authority having jurisdiction (AHJ) would be notified and there was no contact information for the AHJ.

Interview with Staff E and Staff F at time of review verified the deficient practice.

Based on record review, and staff interview, the facility failed to ensure a Fire Watch Policy was developed in accordance with NFPA 101 - 2012 Edition Sections 19.3.5.1, 9.7.5, and NFPA 25 2011 Edition Section 15.5.2 through 15.5.2 (9). This deficient practice had the potential to affect all patients receiving services from the facility.

Findings include:

Record review on 12/09/19 between 12:45 P.M. to 4:30 P.M. revealed no Fire Watch Procedure was available for review. A copy of the facility fire watch policy was requested at entrance conference with the Staff E and Staff F. The document provided for review for the fire watch procedures did not address that if the sprinkler system was out of service for ten hours or more that the building would be evacuated, or a fire watch initiated. It did not address the assigning individuals to conduct a fire watch as their sole duties. This document also did not indicate that when a fire watch would be initiated the authority having jurisdiction (AHJ) would be notified and there was no contact information for the AHJ.

Interview with Staff E and Staff F at time of review verified the deficient practice.