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Based on interview and record review, it was determined the facility failed to ensure the facility had a complete Evacuation and Relocation Plan for the protection of all patients and for their evacuation in the event of an emergency, in accordance with National Fire Protection Association (NFPA) standards. The deficient practice has the potential to affect eight (08) of eight (08) smoke compartments, all residents, staff and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey, the census was eleven (11).

The findings include:

Record review on 05/03/17 at 1:40 PM with the Maintenance Director revealed the facility failed to provide a complete Evacuation and Relocation Plan for the facility. The facility's plan failed to include two (02) of the nine (09) required components. The facility's Evacuation and Relocation Plan did not include: 1) the transmission of the alarm to the Fire Department; 2) the emergency phone call to the Fire Department.

Interview on 05/03/17 at 1:41 PM with the Maintenance Director and the Chief Executive Officer revealed they were not aware of the nine (09) required components of the Evacuation and Relocation plan.

The census of eleven (11) was verified by the Chief Executive Officer on 05/03/17. The findings were acknowledged by the Chief Executive Officer and verified by the Maintenance Director at the exit interview on 05/03/17.


Actual NFPA Standard:

Reference: NFPA 101 (2012 edition)
19.7.1 Evacuation and Relocation Plan and Fire Drills.
19.7.1.1
The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center.

19.7.2.2 Fire Safety Plan. A written health care occupancy fire safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire

Based on generator testing record review and interview, the facility failed to maintain the generator according to National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect eight (08) of eight (08) smoke compartments, all residents, staff and visitors. The facility has the capacity for twenty-five (25) beds with a census of eleven (11) on the day of the survey.

The findings include:

Generator testing record review on 05/03/17 at 12:47 PM with the Maintenance Director revealed the facility did not document the transfer times at least monthly when the power was transferred during the monthly testing of the generator transfer switch.

Interview on 05/03/17 at 12:48 PM with the Maintenance Director revealed he was aware of the requirements for generator testing. Further interview revealed that the Maintenance Director was not aware that the contractor who performed the monthly tests was not recording the transfer times on the monthly reports.

The census of eleven (11) was verified by the Chief Executive Officer on 05/03/17. The findings were acknowledged by the CEO and verified by the Maintenance Director at the exit interview on 05/03/17.


Actual NFPA Standard:

NFPA 99 Health Care Facilities Code (2012 Edition)
Chapter 6 Electrical Systems

6.4.3 Performance Criteria and Testing (Type 1 EES).

6.4.3.1 Source. The life safety and critical branches shall be installed
and connected to the alternate power source specified in
6.4.1.1.4 and 6.4.1.1.5 so that all functions specified herein for
the life safety and critical branches are automatically restored to
operation within 10 seconds after interruption of the normal
source.


6.5 Essential Electrical System

6.5.4.1.1.1 Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment,
including all appurtenance parts, shall be so maintained as to be capable of supplying service within the shortest time practicable
and within the 10-second interval specified in 6.4.1.1.7 and 6.4.3.1.

6.5.4.2 Record Keeping. Awritten record of inspection, performance, exercising period, and repairs shall be regularly maintained
and available for inspection by the authority having jurisdiction