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Tag No.: K0067
This is a recite.
Based on review of facility documentation and staff interview, the facility failed to follow their plan of correction to ensure that fire and smoke dampers completed with the provisions of NFPA 90A with regards to testing. The facility had a census of 102 patients at the time of the survey.
Findings include:
On 04/10/14, at 2:00 PM, an interview conducted with Staff D revealed the facility obtained a contract with an outside service company to evaluate the location of smoke and fire dampers and to complete repairs on the dampers. Staff D stated the smoke and fire dampers found to be deficient at the time of the previous survey on 02/06/14, in regards to testing, have not currently been tested or repaired. Staff D stated the facility has arranged for an outside service company to identify the locations of the dampers, and to perform the testing of the dampers; however, the testing would not be completed until July 2014.
On 04/10/14, a review of 03/10/14 documentation from the outside service company revealed the service company will complete repairs on the dampers by July 1, 2014. Staff D confirmed this documentation.
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