HospitalInspections.org

Based on a review of fire drill records, it was determined that the facility staff have not conducted fire exit drills in accordance with National Fire Protection Association (NFPA) 101 "The Life Safety Code" (LSC) 2000 edition section 19.7.1.2. Not conducting fire exit drills could allow confusion and delay in the staff response, which would negatively impact all occupants of the building in a fire emergency.

Findings include:

At the conclusion of the facility tour on 8-11-15 at 10:30AM, documentation revealed that fire exit drills are not being conducted to meet the intent of the LSC. Two drill are conducted per quarter and most often they are not in the patient care areas.

This deficient practice was confirmed by the Director of Facility Maintenance (BM) and the Administrator (DO)) at the time of exit.

Based on observation and interview, the facility's fire alarm system is not maintained in conformance with NFPA 70(99) and NFPA 72(99) edition. 9.6.1.4.This deficient practice could affect all building occupants.

Findings include:

At the conclusion of the inspection tour at approximately 10:30AM on 8-11-15 review of available documentation indicated that the last annually required inspection, testing, and maintenance of the fire alarm system, in accordance with NFPA 72, was conducted on 3-5-14

This deficient practice was not verified by the facility Maintained Director (BM) at the time of this inspection.

Based on interview, the facility does not have an appropriate written policy addressing actions to be taken by staff in the event the sprinkler system is out of service. This deficient practice could affect all residents, staff and visitors.

Findings include:

Upon completion of the facility tour on 8-11-15 at approximately 10:00AM, based on interview with the director of maintenance, it was discovered that the facility does not have an up-dated written policy on file addressing the actions required by staff in the event the required complete automatic fire sprinkler system is out of service for more than 4 hours in a 24-hour period, as required by LSC(00) section 9.7.6.1.

This deficient practice was confirmed by Maintenance Director (BM) and the administrator at the time of exit.

Based on interview, the facility does not have an appropriate written policy to deal with periods of time that the fire alarm may be out of service. This deficient practice could affect all residents, staff and visitors.

Finding include:

Upon conclusion of the facility tour on 8-11-15 at approximately 10:00AM, based on interview with the director of maintenance, the facility does not have an up-dated written policy on file that would outline the actions required to be carried out in the event of a fire alarm outage lasting more than 4 hours in a 24-hour period, as required by LSC(00, Section 9.7.6.1.

This deficient practice was confirmed by the Maintenance Director (BM) and the administrator at the time of exit.

Based on a review of fire drill records, it was determined that the facility staff have not conducted fire exit drills in accordance with National Fire Protection Association (NFPA) 101 "The Life Safety Code" (LSC) 2000 edition section 19.7.1.2. Not conducting fire exit drills could allow confusion and delay in the staff response, which would negatively impact all occupants of the building in a fire emergency.

Findings include:

At the conclusion of the facility tour on 8-11-15 at 10:30AM, documentation revealed that fire exit drills are not being conducted to meet the intent of the LSC. Two drill are conducted per quarter and most often they are not in the patient care areas.

This deficient practice was confirmed by the Director of Facility Maintenance (BM) and the Administrator (DO)) at the time of exit.

Based on observation and interview, the facility's fire alarm system is not maintained in conformance with NFPA 70(99) and NFPA 72(99) edition. 9.6.1.4.This deficient practice could affect all building occupants.

Findings include:

At the conclusion of the inspection tour at approximately 10:30AM on 8-11-15 review of available documentation indicated that the last annually required inspection, testing, and maintenance of the fire alarm system, in accordance with NFPA 72, was conducted on 3-5-14

This deficient practice was not verified by the facility Maintained Director (BM) at the time of this inspection.

Based on interview, the facility does not have an appropriate written policy addressing actions to be taken by staff in the event the sprinkler system is out of service. This deficient practice could affect all residents, staff and visitors.

Findings include:

Upon completion of the facility tour on 8-11-15 at approximately 10:00AM, based on interview with the director of maintenance, it was discovered that the facility does not have an up-dated written policy on file addressing the actions required by staff in the event the required complete automatic fire sprinkler system is out of service for more than 4 hours in a 24-hour period, as required by LSC(00) section 9.7.6.1.

This deficient practice was confirmed by Maintenance Director (BM) and the administrator at the time of exit.

Based on interview, the facility does not have an appropriate written policy to deal with periods of time that the fire alarm may be out of service. This deficient practice could affect all residents, staff and visitors.

Finding include:

Upon conclusion of the facility tour on 8-11-15 at approximately 10:00AM, based on interview with the director of maintenance, the facility does not have an up-dated written policy on file that would outline the actions required to be carried out in the event of a fire alarm outage lasting more than 4 hours in a 24-hour period, as required by LSC(00, Section 9.7.6.1.

This deficient practice was confirmed by the Maintenance Director (BM) and the administrator at the time of exit.