HospitalInspections.org

Based on observation, record review and interview, the facility failed to meet the Condition of Participation (COP) for Governing Body as evidenced by the failure to meet COP for Physical Environment under Fire Life Safety Code 42 CFR 482.41(b) ( refer to A-700, A-709, and A710), and 42 CFR 482.13 Patient Rights (refer to A-115, and A -144).

Based on obervation record review and interview, the Chief Executive Officer (CEO) failed to responsibly manage the hospital as evidenced by :
1. failure to maintain fire protection and occupancy features necessary to minimize danger to residents from smoke, fumes or panic should a fire occur. The facility did not maintain six corridor doors (Rooms 303, 304, 305, 306, 309, and recreation (common) area) to prevent impediments to closing it to limit the transfer of smoke / heated gases should a fire occur. This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering the lives of the building occupants.
2. failure to ensure that the exits are readily accessible at all times. This could delay or deny escape from one area of the structure to another or outside posing a serious risk to patient safety.
3. failure to follow procedures pertaining to training and practicing fire drills. A lack of these training exercises could in the event of an internal or external disaster cause confusion and/or panic from a lack of knowledge for staff and raise a high potential for negative outcomes to the safety of patients and staff, and the other building occupants.


Findings Include:

1. Observations and interviews with facility staff by Fire Life Safety surveyor showed that the facility failed to maintain fire protection and occupancy features necessary to minimize danger to residents from smoke, fumes or panic should a fire occur. The facility did not maintain six corridor doors to prevent impediments to closing it to limit the transfer of smoke / heated gases should a fire occur. This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering the lives of the building occupants.

Observation during the life safety tour of the third floor on 09/06/11 with the Maintenance Director and the Safety Officer showed that patients room doors and recreation area have been removed.

In a 10 bed lock down unit occupied by the U.S. Immigration and Customs Enforcement (ICE), it was observed at 2:45 p.m. that the facility had removed five patient's doors(303, 304,305,306, and 309) and one door for the recreation room. All of these doors lead directly into the exit corridor. The Director of Plant Operation stated that the ICE staff required that these doors be removed. The ICE unit moved into the facility in September of 2010. During the tour of the ICE unit, staff informed the surveyor that there were nine detainees and each detainee has two ICE staff. During the tour of the ICE unit on 09/07/11 it was observed the unit has nine detainees and one ICE staff per detainee.

This deficiency was confirmed by Plant Operation Manager, Safety Officer and the Compliance Officer/Risk Manager 5:10 p.m. on 09/06/11.

Observation conducted on 09/08 and 09/09/2011 showed that the identified rooms still do not have the required doors.

Interview with the Plant Operations Manager on 9/09/2011 revealed that the hospital has ordered the doors and that delivery and installation was expected to be on Monday 09/12/2011.

NFPA 101 (2000 edition)


2. Observations made during FLS tour and staff interview of the facility on 09/06/11 & 09/07/11 showed that the exits are not readily accessible at all times. This could delay or deny escape from one area of the structure to another or outside posing a serious risk to patient safety.

FLS surveyors observed with the Plant Operation Manager and the Safety Officer at 3:20 p.m. that the exit door leading to the stairwell on the third floor, the ICE unit was being obstructed by a desk and two chairs. It was noted that this condition also obstructed the fire alarm pull station. At 3:50 p.m. it was observed on the medical surgery floor (third floor) that a construction wall had been installed to remodel the new nourishment room. This condition reduced the corridor width to four feet. The plant operation manager stated that this project was on hold due to some additional requirements by the hospital.
This deficiency was confirmed by Plant Operation Manager, Safety Officer and the Compliance Officer/Risk Manager 5:10 p.m. on 09/06/11.

The construction wall, the desk and chairs were removed on 09/07/11 during the survey.

NFPA 101 (2000 edition).

3. Review of fire drill reports and staff interview revealed that the Hospital was not following procedures pertaining to training and practicing fire drills. A lack of these training exercises could in the event of an internal or external disaster cause confusion and/or panic from a lack of knowledge for staff and raise a high potential for negative outcomes to the safety of patients and staff, and the other building occupants.


Review of the fire drill reports for 2010 & 2011 with the Plant Operations Manager and the Facilities Safety Officer showed that no documentation to indicate that this secured lock down unit had conducted a fire drill within the last twelve months. During staff interview at 3:45 p.m. it was noted that ICE staff have not been trained in hospital procedure for a fire emergency. Surveyor interviewed eight ICE members during this survey and all eight staff stated they have not been trained by hospital staff on the requirements for a fire emergency in the hospital.

This unit opened in September of 2010, it was noted that there were no fire drills in this unit has been conducted. None of the ICE staff knew what the acronym for R.A.C.E. (Rescue, Alarm, Confine, and Extinguish) or P.A.S.S. (Pull, Aim, Squeeze, and Sweep) meant. Further interview of ICE staff revealed that none of them knew where the nearest fire alarm pull station was located in this unit.

NFPA 101 (2000 edition) requires that health care facilities conduct at least one fire drill per shift per quarter. Therefore each shift must participate in a minimum of four (4) fire drills every year. The intent of this requirement is for each shift to participate in a fire drill approximately every 90 days This allows the staff to train and practice emergency procedures and to maintain a state of readiness in case of an actual fire emergency. All staff persons subject to the fire drill must participate to establish conduct of the drill as a matter of routine.

It is also required that observers be positioned in several areas in and around the
"fire" area. Specifically, there must be an observer in the smoke compartment where the fire is discovered; an observer in the smoke compartments on both sides of the fire compartment; and observers in the smoke compartments (floors) above and below the smoke compartment where the fire is discovered.

The training consists of a table top in-service, an internal disaster scenario, and an external disaster scenario, at six month intervals.

No documentation was provided to indicate that this procedure was being adhered to.
This deficiency was confirmed by Plant Operation Manager, Safety Officer and the Compliance Officer/Risk Manager 5:10 p.m. on 09/06/11.

Based on obervation record review and interview, the Governing Body failed to ensure that a contractor of service comply with the applicable provisions of the Life Safety Code of the National Fire Protection Association as evidenced by the removal of 5 (303, 304, 305, 306, and 309) patient room doors, and recreation area.

Findings Include:

1. Observations and interviews with facility staff by Fire Life Safety and health surveyors conducted from 9/6 to 9/9/2011 showed that the facility failed to maintain fire protection and occupancy features necessary to minimize danger to residents from smoke, fumes or panic should a fire occur. The facility did not maintain six corridor doors to prevent impediments to closing it to limit the transfer of smoke / heated gases should a fire occur. This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering the lives of the building occupants.

Observation during the life safety tour of the third floor on 09/06/11 with the Maintenance Director and the Safety Officer showed that patients room doors (303, 304,305,306, and 309) and recreation area have been removed.

In a 10 bed lock down unit occupied by the U.S. Immigration and Customs Enforcement (ICE), it was observed at 2:45 p.m. that the facility had removed five patient's doors(303, 304,305,306, and 309) and one door for the recreation room. All of these doors lead directly into the exit corridor. The Director of Plant Operation stated that the ICE staff required that these doors be removed. The ICE unit moved into the facility in September of 2010. During the tour of the ICE unit, staff informed the surveyor that there were nine detainees and each detainee has two ICE staff. During the tour of the ICE unit on 09/07/11 it was observed the unit has nine detainees and one ICE staff per detainee.

This deficiency was confirmed by Plant Operation Manager, Safety Officer and the Compliance Officer/Risk Manager 5:10 p.m. on 09/06/11.

Observation conducted on 09/08 and 09/09/2011 showed that the identified rooms still do not have the required doors.

Interview with the ICE Supervisor on 09/08/2011 around 1:20 PM revealed that for security and safety requested that the patient room doors be removed on the third floor. The ICE Supervisor further stated that if their Agency prefer that there are no doors but would be willing to comply if doors are required.

Review of hospital contract with ICE revealed a memorandum of agreement with no specifics related to fire life safety, and delineation of responsibilities for the hospital Staff and ICE staff.

Interview with the Plant Operations Manager on 9/09/2011 revealed that the hospital has ordered the doors and that delivery and installation was expected to be on Monday 09/12/2011.

Based on observation, record review and interview, the facility failed to meet the Condition of Participation (COP) for Patient Rights as evidenced by the failure to meet the life safety for fire requirements and applicable provisions of the Life Safety Code of the National Fire Protection Association. Refer to A-144

Based on observation, record review and interview, the hospital failed to ensure patient's rights to receive care in safe settng as evidenced by failure to meet the life safety for fire requirements and applicable provisions of the Life Safety Code of the National Fire Protection Association.

Findings Include:

1. Observations and interviews with facility staff by Fire Life Safety surveyor showed that the facility failed to maintain fire protection and occupancy features necessary to minimize danger to residents from smoke, fumes or panic should a fire occur. The facility did not maintain six corridor doors to prevent impediments to closing it to limit the transfer of smoke / heated gases should a fire occur. This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering the lives of the building occupants.

Observation during the life safety tour of the third floor on 09/06/11 with the Maintenance Director and the Safety Officer showed that patients room doors and recreation area have been removed.

In a 10 bed lock down unit occupied by the U.S. Immigration and Customs Enforcement (ICE), it was observed at 2:45 p.m. that the facility had removed five patient's doors(303, 304,305,306, and 309) and one door for the recreation room. All of these doors lead directly into the exit corridor. The Director of Plant Operation stated that the ICE staff required that these doors be removed. The ICE unit moved into the facility in September of 2010. During the tour of the ICE unit, staff informed the surveyor that there were nine detainees and each detainee has two ICE staff. During the tour of the ICE unit on 09/07/11 it was observed the unit has nine detainees and one ICE staff per detainee.

This deficiency was confirmed by Plant Operation Manager, Safety Officer and the Compliance Officer/Risk Manager 5:10 p.m. on 09/06/11.

Observation conducted on 09/08 and 09/09/2011 showed that the identified rooms still do not have the required doors.

Interview with the Plant Operations Manager on 9/09/2011 revealed that the hospital has ordered the doors and that delivery and installation was expected to be on Monday 09/12/2011.

NFPA 101 (2000 edition)


2. Observations made during FLS tour and staff interview of the facility on 09/06/11 & 09/07/11 showed that the exits are not readily accessible at all times. This could delay or deny escape from one area of the structure to another or outside posing a serious risk to patient safety.

FLS surveyors observed with the Plant Operation Manager and the Safety Officer at 3:20 p.m. that the exit door leading to the stairwell on the third floor, the ICE unit was being obstructed by a desk and two chairs. It was noted that this condition also obstructed the fire alarm pull station. At 3:50 p.m. it was observed on the medical surgery floor (third floor) that a construction wall had been installed to remodel the new nourishment room. This condition reduced the corridor width to four feet. The plant operation manager stated that this project was on hold due to some additional requirements by the hospital.
This deficiency was confirmed by Plant Operation Manager, Safety Officer and the Compliance Officer/Risk Manager 5:10 p.m. on 09/06/11.

The construction wall, the desk and chairs were removed on 09/07/11 during the survey.

NFPA 101 (2000 edition).

3. Review of fire drill reports and staff interview revealed that the Hospital was not following procedures pertaining to training and practicing fire drills. A lack of these training exercises could in the event of an internal or external disaster cause confusion and/or panic from a lack of knowledge for staff and raise a high potential for negative outcomes to the safety of patients and staff, and the other building occupants.


Review of the fire drill reports for 2010 & 2011 with the Plant Operations Manager and the Facilities Safety Officer showed that no documentation to indicate that this secured lock down unit had conducted a fire drill within the last twelve months. During staff interview at 3:45 p.m. it was noted that ICE staff have not been trained in hospital procedure for a fire emergency. Surveyor interviewed eight ICE members during this survey and all eight staff stated they have not been trained by hospital staff on the requirements for a fire emergency in the hospital.

This unit opened in September of 2010, it was noted that there were no fire drills in this unit has been conducted. None of the ICE staff knew what the acronym for R.A.C.E. (Rescue, Alarm, Confine, and Extinguish) or P.A.S.S. (Pull, Aim, Squeeze, and Sweep) meant. Further interview of ICE staff revealed that none of them knew where the nearest fire alarm pull station was located in this unit.

NFPA 101 (2000 edition) requires that health care facilities conduct at least one fire drill per shift per quarter. Therefore each shift must participate in a minimum of four (4) fire drills every year. The intent of this requirement is for each shift to participate in a fire drill approximately every 90 days This allows the staff to train and practice emergency procedures and to maintain a state of readiness in case of an actual fire emergency. All staff persons subject to the fire drill must participate to establish conduct of the drill as a matter of routine.

It is also required that observers be positioned in several areas in and around the
"fire" area. Specifically, there must be an observer in the smoke compartment where the fire is discovered; an observer in the smoke compartments on both sides of the fire compartment; and observers in the smoke compartments (floors) above and below the smoke compartment where the fire is discovered.

The training consists of a table top in-service, an internal disaster scenario, and an external disaster scenario, at six month intervals.

No documentation was provided to indicate that this procedure was being adhered to.
This deficiency was confirmed by Plant Operation Manager, Safety Officer and the Compliance Officer/Risk Manager 5:10 p.m. on 09/06/11.


The failure of the facility to have the required FLS doors was determined by the Agency on 09/09/2011 to be an ongoing immediate jeopardy.

Based on observation, record review and interview, the hospital failed to meet the Condition of Participation (COP) for Physical Environment 42 CFR 482.41 as evidenced by the Fire Life Safety's findings conducted on September 6, and 7, 2011.
1. failure to maintain fire protection and occupancy features necessary to minimize danger to residents from smoke, fumes or panic should a fire occur. The facility did not maintain six corridor doors (Rooms 303, 304, 305, 306, 309, and recreation (common) area) to prevent impediments to closing it to limit the transfer of smoke / heated gases should a fire occur. This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering the lives of the building occupants.
2. failure to ensure that the exits are readily accessible at all times. This could delay or deny escape from one area of the structure to another or outside posing a serious risk to patient safety.
3. failure to follow procedures pertaining to training and practicing fire drills. A lack of these training exercises could in the event of an internal or external disaster cause confusion and/or panic from a lack of knowledge for staff and raise a high potential for negative outcomes to the safety of patients and staff, and the other building occupants.

The hospital's deficient Fire Life Safety Code's practices resulted to an "Ongoing Immediate Jeopardy". Refer to A-710

Based on observation, record review and interview, the hospital failed to ensure that life safety from fire requirements are met as evidenced by :
1. failure to maintain fire protection and occupancy features necessary to minimize danger to residents from smoke, fumes or panic should a fire occur. The facility did not maintain six corridor doors (Rooms 303, 304, 305, 306, 309, and recreation (common) area) to prevent impediments to closing it to limit the transfer of smoke / heated gases should a fire occur. This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering the lives of the building occupants.
2. failure to ensure that the exits are readily accessible at all times. This could delay or deny escape from one area of the structure to another or outside posing a serious risk to patient safety.
3. failure to follow procedures pertaining to training and practicing fire drills. A lack of these training exercises could in the event of an internal or external disaster cause confusion and/or panic from a lack of knowledge for staff and raise a high potential for negative outcomes to the safety of patients and staff, and the other building occupants.


Findings Include:

1. Observations and interviews with facility staff by Fire Life Safety surveyor showed that the facility failed to maintain fire protection and occupancy features necessary to minimize danger to residents from smoke, fumes or panic should a fire occur. The facility did not maintain six corridor doors to prevent impediments to closing it to limit the transfer of smoke / heated gases should a fire occur. This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering the lives of the building occupants.

Observation during the life safety tour of the third floor on 09/06/11 with the Maintenance Director and the Safety Officer showed that patients room doors and recreation area have been removed.

In a 10 bed lock down unit occupied by the U.S. Immigration and Customs Enforcement (ICE), it was observed at 2:45 p.m. that the facility had removed five patient's doors(303, 304,305,306, and 309) and one door for the recreation room. All of these doors lead directly into the exit corridor. The Director of Plant Operation stated that the ICE staff required that these doors be removed. The ICE unit moved into the facility in September of 2010. During the tour of the ICE unit, staff informed the surveyor that there were nine detainees and each detainee has two ICE staff. During the tour of the ICE unit on 09/07/11 it was observed the unit has nine detainees and one ICE staff per detainee.

This deficiency was confirmed by Plant Operation Manager, Safety Officer and the Compliance Officer/Risk Manager 5:10 p.m. on 09/06/11.

Observation conducted on 09/08 and 09/09/2011 showed that the identified rooms still do not have the required doors.

Interview with the Plant Operations Manager on 9/09/2011 revealed that the hospital has ordered the doors and that delivery and installation was expected to be on Monday 09/12/2011.

NFPA 101 (2000 edition)


2. Observations made during FLS tour and staff interview of the facility on 09/06/11 & 09/07/11 showed that the exits are not readily accessible at all times. This could delay or deny escape from one area of the structure to another or outside posing a serious risk to patient safety.

FLS surveyors observed with the Plant Operation Manager and the Safety Officer at 3:20 p.m. that the exit door leading to the stairwell on the third floor, the ICE unit was being obstructed by a desk and two chairs. It was noted that this condition also obstructed the fire alarm pull station. At 3:50 p.m. it was observed on the medical surgery floor (third floor) that a construction wall had been installed to remodel the new nourishment room. This condition reduced the corridor width to four feet. The plant operation manager stated that this project was on hold due to some additional requirements by the hospital.
This deficiency was confirmed by Plant Operation Manager, Safety Officer and the Compliance Officer/Risk Manager 5:10 p.m. on 09/06/11.

The construction wall, the desk and chairs were removed on 09/07/11 during the survey.

NFPA 101 (2000 edition).

3. Review of fire drill reports and staff interview revealed that the Hospital was not following procedures pertaining to training and practicing fire drills. A lack of these training exercises could in the event of an internal or external disaster cause confusion and/or panic from a lack of knowledge for staff and raise a high potential for negative outcomes to the safety of patients and staff, and the other building occupants.


Review of the fire drill reports for 2010 & 2011 with the Plant Operations Manager and the Facilities Safety Officer showed that no documentation to indicate that this secured lock down unit had conducted a fire drill within the last twelve months. During staff interview at 3:45 p.m. it was noted that ICE staff have not been trained in hospital procedure for a fire emergency. Surveyor interviewed eight ICE members during this survey and all eight staff stated they have not been trained by hospital staff on the requirements for a fire emergency in the hospital.

This unit opened in September of 2010, it was noted that there were no fire drills in this unit has been conducted. None of the ICE staff knew what the acronym for R.A.C.E. (Rescue, Alarm, Confine, and Extinguish) or P.A.S.S. (Pull, Aim, Squeeze, and Sweep) meant. Further interview of ICE staff revealed that none of them knew where the nearest fire alarm pull station was located in this unit.

NFPA 101 (2000 edition) requires that health care facilities conduct at least one fire drill per shift per quarter. Therefore each shift must participate in a minimum of four (4) fire drills every year. The intent of this requirement is for each shift to participate in a fire drill approximately every 90 days This allows the staff to train and practice emergency procedures and to maintain a state of readiness in case of an actual fire emergency. All staff persons subject to the fire drill must participate to establish conduct of the drill as a matter of routine.

It is also required that observers be positioned in several areas in and around the
"fire" area. Specifically, there must be an observer in the smoke compartment where the fire is discovered; an observer in the smoke compartments on both sides of the fire compartment; and observers in the smoke compartments (floors) above and below the smoke compartment where the fire is discovered.

The training consists of a table top in-service, an internal disaster scenario, and an external disaster scenario, at six month intervals.

No documentation was provided to indicate that this procedure was being adhered to.
This deficiency was confirmed by Plant Operation Manager, Safety Officer and the Compliance Officer/Risk Manager 5:10 p.m. on 09/06/11.

The failure of the facility to have the required FLS doors was determined by the Agency on 09/09/2011 to be an ongoing immediate jeopardy.

Refer to K-0018, K-0038, and K-0050

Based on observation, record review and interview, the hospital failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association as evidenced by:
1. failure to maintain fire protection and occupancy features necessary to minimize danger to residents from smoke, fumes or panic should a fire occur. The facility did not maintain six corridor doors (Rooms 303, 304, 305, 306, 309, and recreation (common) area) to prevent impediments to closing it to limit the transfer of smoke / heated gases should a fire occur. This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering the lives of the building occupants.
2. failure to ensure that the exits are readily accessible at all times. This could delay or deny escape from one area of the structure to another or outside posing a serious risk to patient safety.
3. failure to follow procedures pertaining to training and practicing fire drills. A lack of these training exercises could in the event of an internal or external disaster cause confusion and/or panic from a lack of knowledge for staff and raise a high potential for negative outcomes to the safety of patients and staff, and the other building occupants.

Findings Include:

1. Observations and interviews with facility staff by Fire Life Safety surveyor showed that the facility failed to maintain fire protection and occupancy features necessary to minimize danger to residents from smoke, fumes or panic should a fire occur. The facility did not maintain six corridor doors to prevent impediments to closing it to limit the transfer of smoke / heated gases should a fire occur. This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering the lives of the building occupants.

Observation during the life safety tour of the third floor on 09/06/11 with the Maintenance Director and the Safety Officer showed that patients room doors and recreation area have been removed.

In a 10 bed lock down unit occupied by the U.S. Immigration and Customs Enforcement (ICE), it was observed at 2:45 p.m. that the facility had removed five patient's doors(303, 304,305,306, and 309) and one door for the recreation room. All of these doors lead directly into the exit corridor. The Director of Plant Operation stated that the ICE staff required that these doors be removed. The ICE unit moved into the facility in September of 2010. During the tour of the ICE unit, staff informed the surveyor that there were nine detainees and each detainee has two ICE staff. During the tour of the ICE unit on 09/07/11 it was observed the unit has nine detainees and one ICE staff per detainee.

This deficiency was confirmed by Plant Operation Manager, Safety Officer and the Compliance Officer/Risk Manager 5:10 p.m. on 09/06/11.

Observation conducted on 09/08 and 09/09/2011 showed that the identified rooms still do not have the required doors.

Interview with the Plant Operations Manager on 9/09/2011 revealed that the hospital has ordered the doors and that delivery and installation was expected to be on Monday 09/12/2011.

NFPA 101 (2000 edition)


2. Observations made during FLS tour and staff interview of the facility on 09/06/11 & 09/07/11 showed that the exits are not readily accessible at all times. This could delay or deny escape from one area of the structure to another or outside posing a serious risk to patient safety.

FLS surveyors observed with the Plant Operation Manager and the Safety Officer at 3:20 p.m. that the exit door leading to the stairwell on the third floor, the ICE unit was being obstructed by a desk and two chairs. It was noted that this condition also obstructed the fire alarm pull station. At 3:50 p.m. it was observed on the medical surgery floor (third floor) that a construction wall had been installed to remodel the new nourishment room. This condition reduced the corridor width to four feet. The plant operation manager stated that this project was on hold due to some additional requirements by the hospital.
This deficiency was confirmed by Plant Operation Manager, Safety Officer and the Compliance Officer/Risk Manager 5:10 p.m. on 09/06/11.

The construction wall, the desk and chairs were removed on 09/07/11 during the survey.

NFPA 101 (2000 edition).

3. Review of fire drill reports and staff interview revealed that the Hospital was not following procedures pertaining to training and practicing fire drills. A lack of these training exercises could in the event of an internal or external disaster cause confusion and/or panic from a lack of knowledge for staff and raise a high potential for negative outcomes to the safety of patients and staff, and the other building occupants.


Review of the fire drill reports for 2010 & 2011 with the Plant Operations Manager and the Facilities Safety Officer showed that no documentation to indicate that this secured lock down unit had conducted a fire drill within the last twelve months. During staff interview at 3:45 p.m. it was noted that ICE staff have not been trained in hospital procedure for a fire emergency. Surveyor interviewed eight ICE members during this survey and all eight staff stated they have not been trained by hospital staff on the requirements for a fire emergency in the hospital.

This unit opened in September of 2010, it was noted that there were no fire drills in this unit has been conducted. None of the ICE staff knew what the acronym for R.A.C.E. (Rescue, Alarm, Confine, and Extinguish) or P.A.S.S. (Pull, Aim, Squeeze, and Sweep) meant. Further interview of ICE staff revealed that none of them knew where the nearest fire alarm pull station was located in this unit.

NFPA 101 (2000 edition) requires that health care facilities conduct at least one fire drill per shift per quarter. Therefore each shift must participate in a minimum of four (4) fire drills every year. The intent of this requirement is for each shift to participate in a fire drill approximately every 90 days This allows the staff to train and practice emergency procedures and to maintain a state of readiness in case of an actual fire emergency. All staff persons subject to the fire drill must participate to establish conduct of the drill as a matter of routine.

It is also required that observers be positioned in several areas in and around the
"fire" area. Specifically, there must be an observer in the smoke compartment where the fire is discovered; an observer in the smoke compartments on both sides of the fire compartment; and observers in the smoke compartments (floors) above and below the smoke compartment where the fire is discovered.

The training consists of a table top in-service, an internal disaster scenario, and an external disaster scenario, at six month intervals.

No documentation was provided to indicate that this procedure was being adhered to.
This deficiency was confirmed by Plant Operation Manager, Safety Officer and the Compliance Officer/Risk Manager 5:10 p.m. on 09/06/11.


The failure of the facility to have the required FLS doors was determined by the Agency on 09/09/2011 to be an ongoing immediate jeopardy.

Refer to K-0018, K-0038, and K-0050