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Based upon a review of records and staff interview, the facility fails to assure that persons responsible for inspecting and maintaining door assemblies are qualified to perform the inspections and required maintenance. The deficient practice of failing to properly maintaining smoke and fire barrier doors would not prevent the passage of fire or smoke to other areas of the building, affecting all patients, visitors and staff in 7 of 7 smoke zones. The facility has a capacity of 25 with a census of 4 at the time of this survey.

Findings include:

During the tour conducted on 07/25/2017, between 1:30 p.m. and 2:30 p.m., a review of records revealed that there is no documentation available assuring that persons performing inspections and repairs on smoke and fire barrier doors are trained and qualified.

Maintenance Supervisor and Maintenance Staff A and B were present and acknowledged the results of the records review.

NFPA Standard: Requirements for all fire-rated door assemblies to be inspected and maintained by a qualified person: 2010 NFPA 80, 5.2.1

NFPA Standard: Qualified Person. A person who, by possession of a recognized degree, certificate, professional standing, or skill, and who, by knowledge, training, and experience, has demonstrated the ability to deal with the subject matter, the work, or the project. 2010 NFPA 80, 3.3.95

5.2.3 Functional Testing. 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. 2010 NFPA 80, 5.2.3

Based upon a review of records and staff interview, the facility fails to assure that all personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. The deficient practice could result in the mishandling of medical gases and cylinders, affecting all patients, visitors and staff in 7 of 7 smoke zones. The facility has a capacity of 25 with a census of 4 at the time of this survey.

Findings include:

During the tour conducted on 07/25/2017, between 1:30 p.m. and 2:30 p.m., a review of records revealed that there is no documented training and certification or credentialing of persons who handle medical gases and cylinders.

Maintenance Supervisor and Maintenance Staff A and B were present and acknowledged the results of the records review.

NFPA Standard: Personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained in the maintenance and operation of equipment.
11.5.2.1 (NFPA 99)

NFPA Standard: Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040.
5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99)