HospitalInspections.org

Through observation during the survey,
December 30, 2013, it was determined the
facility failed to maintain all egress paths free of
obstructions.

During the walk-through of the facility, with the
Director of Plant Operations, the
sidewalk/egress path frat the courtyard/egress
area on the first (1st) floor contained
approximately an 1/8" of snow on the egress
path from two (2) doors.
Note: Corrected during the survey by staff.

Through record review during the survey,
December 30, 2013, it was determined that the
facility failed to have all components required in
the emergency plan.

During the review of the emergency plans, with
the Director of Plant Operations, the emergency
plan for the facility failed to contain four (4)
elements in the emergency plan.
1) Use of Alarms
2) Evacuation of smoke compartment
3) Extinguishment of fire
4) Preparation of other smoke
compartments due to fire (note: the facility
currently evacuates the entire building during
every fire alarm and does not utilize a "Defend
in Place" strategy.)

Through record review and discussions with the
staff during the survey, December 30, 2013, it
was determined that the facility failed to conduct
fire drills at on each shift quarterly.

During the review of the facility records, with the
Director of Plant Operations, the facility failed to
document that a fire drill had occured during the
third (3rd) quarter on the first (1st) shift of the
2013 calendar year.

Through a review of the records during the
survey, December 30, 2013, it was determined
that the facility failed to complete a sensitivity
test on the smoke detectors as required.

During the review of the facility records, with the
Director of Plant Operations, documentation
was not available to verify that the smoke
detectors had been sensitivity tested every
other year as required.
Per the 1999 Edition of NFPA-72 Chapter 7,
Section 7-3, Paragraph 7-3.2.

Through observation during the survey,
December 30, 2013, it was determined the
facility failed to maintain all egress paths free of
obstructions.

During the walk-through of the facility, with the
Director of Plant Operations, the
sidewalk/egress path frat the courtyard/egress
area on the first (1st) floor contained
approximately an 1/8" of snow on the egress
path from two (2) doors.
Note: Corrected during the survey by staff.

Through record review during the survey,
December 30, 2013, it was determined that the
facility failed to have all components required in
the emergency plan.

During the review of the emergency plans, with
the Director of Plant Operations, the emergency
plan for the facility failed to contain four (4)
elements in the emergency plan.
1) Use of Alarms
2) Evacuation of smoke compartment
3) Extinguishment of fire
4) Preparation of other smoke
compartments due to fire (note: the facility
currently evacuates the entire building during
every fire alarm and does not utilize a "Defend
in Place" strategy.)

Through record review and discussions with the
staff during the survey, December 30, 2013, it
was determined that the facility failed to conduct
fire drills at on each shift quarterly.

During the review of the facility records, with the
Director of Plant Operations, the facility failed to
document that a fire drill had occured during the
third (3rd) quarter on the first (1st) shift of the
2013 calendar year.

Through a review of the records during the
survey, December 30, 2013, it was determined
that the facility failed to complete a sensitivity
test on the smoke detectors as required.

During the review of the facility records, with the
Director of Plant Operations, documentation
was not available to verify that the smoke
detectors had been sensitivity tested every
other year as required.
Per the 1999 Edition of NFPA-72 Chapter 7,
Section 7-3, Paragraph 7-3.2.