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Based on observation and interview, the facility had a corridor door that did not meet the requirements of NFPA 101 LSC (00) Section 18.3.6.3.6. This deficient practice could affect the safety of patients, staff and visitors, if smoke from a fire were allowed to enter the exit access corridors making it untenable.

Findings include:

On facility tour between 12:30 PM 11/02/2015 and 1:30 PM on 11/03/2015, it was observed that the following deficient conditions were found to be affecting the corridor doors located within the facility:

1. there is a 1/4 inch gap between the corridor door separating the Emergency Department and the Radiology Department,

2. the patient room door to room 109 did not positively latch into the door frame.


This deficient practices was confirmed by the Environmental Services Director (JS).

Based on observations and staff interview, it was revealed that the facility has failed to provide proper protection for 1 of several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (00) section 18.3.2.1. This deficient conditions could in the event of a fire, allow smoke and flames to spread throughout the effected corridors and areas making them untenable, which could negatively affect the exiting capabilities for patients, staff and visitors.


Findings include:

On facility tour between 12:30 PM 11/02/2015 and 1:30 PM on 11/03/2015, observation revealed, that the following deficient conditions were found affecting the hazardous areas located in the facility:

1. the door to the storage room J142 was not equipped with a self-closing device,

2. the door to soiled lined room L171 did not close and positively latch into the door frame.


This deficient practices was confirmed by the Environmental Services Director (JS).

Based on review of reports, records and interview, it was determined that the facility failed to vary the times and conditions for the required fire drills within the last 12-month period. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect the safety of all patients, visitors and staff.

Findings include:

On facility tour between 12:30 PM 11/02/2015 and 1:30 PM on 11/03/2015, during a fire drill that was held in the Labor and Delivery Unit the following deficient conditions were noted:

1. Staff delayed in responding to the fire drill within the Unit,

2. Carts were located in the corridor,

3. not all staff and employee carry pagers causing a lack of communication by notification as per facility's Fire Emergency Procedure.


This deficient practices was confirmed by the Environmental Services Director (JS).

Based on observation and staff interview, it was revealed that the facility had failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101 and the 1999 NFPA 72. This deficient condition could adversely affect the functioning of the fire alarm system failing to alert the facility in the event of a fire emergency negatively affecting all patients, staff, and visitors of the facility.


Findings include:

On facility tour between 12:30 PM 11/02/2015 and 1:30 PM on 11/03/2015, observations revieled the following deficient conditions were found affecting the Perham Health - New York Mills Clinic:

1. The fire alarm control panel did not have a smoke detector located within 5 feet. This room is not constantly attended and did not have any heating producing equipment located within the room. The only piece of equipment located in the maintenance room that did produce any heat was the facility's computer server. These observations and conditions do not appear to meet the exception to NFPA 72 National Fire Alarm Code section 1-5.6.

2. At the time of the inspection the Perham Health - New York Mills Clinic could not provide any current testing documentation for the annual fire alarm testing. The last noted test date was on a tag stating the system had been tested in 2011.


This deficient practices was confirmed by the Environmental Services Director (JS).

Based on observation and staff interview, it was revealed that the facility had failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 18.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 7.1. This deficient condition could adversely affect the functioning of the fire alarm system, and could delay the timely notification and emergency actions for the facility thus negatively affecting all patients, staff, and visitors of the facility.


Findings include:

On facility tour between 12:30 PM 11/02/2015 and 1:30 PM on 11/03/2015, observations revealed that the following deficient conditions were found affecting the facility's fire alarm system:

1. the facility failed to install manual fire alarm pull station in the nurses stations or in the HUC desk area or within 200 feet of most locations,

2. the smoke detectors located L169, L105, and Imaging Registration Waiting room were within 36" of the HVAC diffuser.


This deficient practices was confirmed by the Environmental Services Director (JS).

Based on observations and staff interview, it was found that the automatic sprinkler system is not installed and maintained in accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems (99). The failure to maintain the sprinkler system in compliance with NFPA 13 (99) could allow system being place out of service causing a decrease in the fire protection system capability in the event of an emergency that would affect the patients, visitors and staff of the facility.

Findings include:

On facility tour between 12:30 PM 11/02/2015 and 1:30 PM on 11/03/2015, observations revealed that the sprinkler heads that are located in the walk in freezer had a clear actuator bulbs.


This deficient practices was confirmed by the Environmental Services Director (JS).

Based on observation and interview, the facility had a corridor door that did not meet the requirements of NFPA 101 LSC (00) Section 18.3.6.3.6. This deficient practice could affect the safety of patients, staff and visitors, if smoke from a fire were allowed to enter the exit access corridors making it untenable.

Findings include:

On facility tour between 12:30 PM 11/02/2015 and 1:30 PM on 11/03/2015, it was observed that the following deficient conditions were found to be affecting the corridor doors located within the facility:

1. there is a 1/4 inch gap between the corridor door separating the Emergency Department and the Radiology Department,

2. the patient room door to room 109 did not positively latch into the door frame.


This deficient practices was confirmed by the Environmental Services Director (JS).

Based on observations and staff interview, it was revealed that the facility has failed to provide proper protection for 1 of several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (00) section 18.3.2.1. This deficient conditions could in the event of a fire, allow smoke and flames to spread throughout the effected corridors and areas making them untenable, which could negatively affect the exiting capabilities for patients, staff and visitors.


Findings include:

On facility tour between 12:30 PM 11/02/2015 and 1:30 PM on 11/03/2015, observation revealed, that the following deficient conditions were found affecting the hazardous areas located in the facility:

1. the door to the storage room J142 was not equipped with a self-closing device,

2. the door to soiled lined room L171 did not close and positively latch into the door frame.


This deficient practices was confirmed by the Environmental Services Director (JS).

Based on review of reports, records and interview, it was determined that the facility failed to vary the times and conditions for the required fire drills within the last 12-month period. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect the safety of all patients, visitors and staff.

Findings include:

On facility tour between 12:30 PM 11/02/2015 and 1:30 PM on 11/03/2015, during a fire drill that was held in the Labor and Delivery Unit the following deficient conditions were noted:

1. Staff delayed in responding to the fire drill within the Unit,

2. Carts were located in the corridor,

3. not all staff and employee carry pagers causing a lack of communication by notification as per facility's Fire Emergency Procedure.


This deficient practices was confirmed by the Environmental Services Director (JS).

Based on observation and staff interview, it was revealed that the facility had failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101 and the 1999 NFPA 72. This deficient condition could adversely affect the functioning of the fire alarm system failing to alert the facility in the event of a fire emergency negatively affecting all patients, staff, and visitors of the facility.


Findings include:

On facility tour between 12:30 PM 11/02/2015 and 1:30 PM on 11/03/2015, observations revieled the following deficient conditions were found affecting the Perham Health - New York Mills Clinic:

1. The fire alarm control panel did not have a smoke detector located within 5 feet. This room is not constantly attended and did not have any heating producing equipment located within the room. The only piece of equipment located in the maintenance room that did produce any heat was the facility's computer server. These observations and conditions do not appear to meet the exception to NFPA 72 National Fire Alarm Code section 1-5.6.

2. At the time of the inspection the Perham Health - New York Mills Clinic could not provide any current testing documentation for the annual fire alarm testing. The last noted test date was on a tag stating the system had been tested in 2011.


This deficient practices was confirmed by the Environmental Services Director (JS).

Based on observation and staff interview, it was revealed that the facility had failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 18.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 7.1. This deficient condition could adversely affect the functioning of the fire alarm system, and could delay the timely notification and emergency actions for the facility thus negatively affecting all patients, staff, and visitors of the facility.


Findings include:

On facility tour between 12:30 PM 11/02/2015 and 1:30 PM on 11/03/2015, observations revealed that the following deficient conditions were found affecting the facility's fire alarm system:

1. the facility failed to install manual fire alarm pull station in the nurses stations or in the HUC desk area or within 200 feet of most locations,

2. the smoke detectors located L169, L105, and Imaging Registration Waiting room were within 36" of the HVAC diffuser.


This deficient practices was confirmed by the Environmental Services Director (JS).

Based on observations and staff interview, it was found that the automatic sprinkler system is not installed and maintained in accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems (99). The failure to maintain the sprinkler system in compliance with NFPA 13 (99) could allow system being place out of service causing a decrease in the fire protection system capability in the event of an emergency that would affect the patients, visitors and staff of the facility.

Findings include:

On facility tour between 12:30 PM 11/02/2015 and 1:30 PM on 11/03/2015, observations revealed that the sprinkler heads that are located in the walk in freezer had a clear actuator bulbs.


This deficient practices was confirmed by the Environmental Services Director (JS).