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Based on record review and interview, the facility did not assure that an adequate, complete policy is in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in any 24-hour period in accordance with National Fire Prevention Association (NFPA) 101, Life Safety Code, 2012 edition, 9.6.1.6. Lack of complete written policies and procedures could result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice affects all occupants of the building, including patients, staff, and visitors. The facility had a capacity of 25 and a census of two at the time of the survey.

Findings include:

1. Record review and interview on 07/26/21 at 9:17 a.m. of the fire watch procedures for a fire alarm system outage, revealed the policy was missing the following information:

(a) To contact the following AHJ's at the beginning and the end of the fire watch: SFM, DIA, and FD (to include phone numbers in the policy)
(b) The fire watch designee is 'dedicated' and the fire watch is 'continuous'

The Maintenance Supervisor verified the documentation at the time of the survey process.

Based on record review and interview, the facility did not assure that an adequate, complete policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than ten hours in any 24-hour period in accordance with National Fire Prevention Association (NFPA) 101, Life Safety Code, 2012 edition, 9.6.1.6. Lack of complete written policies and procedures could result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice affects all occupants of the building, including patients, staff, and visitors. The facility had a capacity of 25 and a census of two patients at the time of the survey.

Findings include:

Record review and interview on 07/26/21 at 10:25 a.m. of the fire watch procedures for a fire alarm system outage, revealed the following items were missing in the policy:

(a) indicating the areas or buildings involved have been inspected and increased risks determined
(b) recommendations have been submitted to management or the property owner\
(c) the insurance company, alarm company, property owner or designated representative, DIA and SFM (wrong number) have been notified
(d) the supervisors in the areas to be affected have been notified
(e) all necessary tools and materials have been assembled on impairment site
(f) address system leakage, ruptured piping, interruption of water supply & equipment failure
(g) listing the phone numbers for the above entities
(h) indicating that the fire watch designee is 'dedicated' and the fire watch is 'continuous'

The Maintenance Supervisor verified the documentation at the time of the survey process.