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Based on staff interview, not all portions of the building fire alarm system are installed in accordance with 19.3.4.

Findings include:

A. Corrected 10/06/09.

NOTE: This deficiency has been transcribed from the CMS Form 2567 prepared following the February 6, 2009 Complaint Investigation.

B. During an interview conducted in his Office on the morning of February 6, 2009, the provider's Administrator was not able to confirm that the notification of the Fire Department is accomplished in accordance with 19.3.4.3.2. and 9.6.4. because he was not able to demonstrate that the system in place is consistent with the requirements for:

1. An auxiliary fire alarm system (also refer to NFPA 72 1999 6-16.),

2. A central station connection (also see NFPA 72 1999 5-2.),

3. A proprietary system (also see NFPA 72 1999 5-3.),

4. A remote station connection (also see NFPA 72 1999 5-4.), OR

5. A plan for the notification of the Fire Department that is acceptable to all Authorities Having Jurisdiction as permitted by the Exception to 9.6.4.
C. During an interview held at the Nurses' Station on the morning of February 6, 2009, that Charge Nurse stated that a designated Staff Member is required to tour those portions of the building identified on the Fire Alarm Control Panel when the building fire alarm is activated. The practice as described does not comply with 9.6.3.3. because the fire alarm signal is not automatically transmitted without delay to the Fire Department.