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Based on record review and interview with the Director of Plant Operations and Director of Quality Data Management it was determined two of twelve fire drills done in July and October of 2016, where one fire drill was a mechanical malfunction of an air conditioning unit that occurred in the facility, and a patient pulled a manual pull station and set off the fire alarm. There were no fire drills conducted in lieu of these two drills for the third and fourth quarter of 2016 for the training of the staff.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 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 a fire, for their evacuation to areas of refuge, and from the 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."

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.2 "Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions."

"Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions."

" When drills are conducted between 9:00 pm and 6:00 am a coded announcement shall be permitted to be used instead of audible alarms."

NFPA 101 Life Safety Code Chapter 19, Section 19.7.2.2 "A written health care occupancy fire safety plan shall provide for the following:

1. Use of alarms
2. Transmission to the fire department
3. Response to alarms
4. Isolation of fire
5. Evacuation of immediate area
6. Evacuation of smoke compartment
7. Preparation of floors and building for evacuation
8. Extinguishment of fire."

Section 19.7.1.3 "Employees of health care occupancies shall be instructed in life safety procedures and devices."

Findings include:

On December 27, 2016 the surveyor accompanied by the Director of Plant Operations
and Director of Quality Data Management reviewed the fire drills for all of 2016. One of twelve fire drills was an actual incident that occurred in the facility due to a malfunction of an air conditioner unit causing the alarm to go off due to smoke in the facility. The second was a false alarm when a manual pull station was pulled by a patient.

The following dates were July 15, 2016 and October 24, 2016. There was no additional fire drills done for the third or fourth quarters in lieu of the two fire drills for the training of the staff

In addition:

The policy and procedures fire manual for the facility fire procedures was missing from one of the nurse's station. It was not found during the survey. The nurses stations on both floors did not have the complete fire policy and procedures in the manuals for each location that was reviewed by the surveyor with the the Director of Plant Operations in the beginning of the survey. Staff members at each nurses station when asked about the fire procedures to review in case of a fire could not locate all the policy and fire procedures for each nurses station. "The Director of Plant Operations advised the surveyor they are missing in the manuals during the survey."

During the exit conference on December 27, 2016 the above findings were again acknowledged by the Director of Plant Operations and Maintenance Technician.

Failing to have fire drills conducted one per quarter per shift per quarter in lieu of either a false alarm or malfunction of an air conditioner unit could result in harm to the patients during a an actual fire or emergency situation. Fire drills are for the training of the staff in an actual event resulting in a fire emergency.

Based on observation and interview with the Director of Plant Operations it was determined the facility did not provide self closing metal containers for all areas outside of the hospital for building where patients or staff smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.4 "Smoking regulations shall be adopted and shall include not less than the following provisions:

Smoking Regulations:

Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 19.7.4 (3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted."
18.7.4, 19.7.4

Findings include:

On December 27, 2016 the surveyor, with the Director of Plant Operations and Maintenance Technician observed three designated patient or staff smoking areas for the facility located just outside of the first and second floors of the hospital. There was no self closing metal containers for the disposal of cigarette butts in these areas at the time of the survey.

During the exit conference on December 27, 2016 the above findings were again acknowledged by the Director of Plant Operations and Maintenance Technician.

Failure to provide self closing metal containers for all areas where designated smoking for patients and staff is allowed could result in harm to the patients or staff if a fire occurs in a trash container if proper containers are not available for the disposal of the cigarette butts from the noncombustible ashtrays.

Based on observation it was determined the facility allowed the use of a multiple outlet adapters, and power strips for appliances; microwaves and refrigerators and did not use the wall outlet receptacles for appliances.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters."

Findings include:

On December 27, 2016 the surveyor, accompanied by the Director of Plant Operations and Maintenance Technician observed the following areas in the facility had power strips being used for appliances and not directly plugged in to the receptacle wall outlets.

1. Two North Managers office
2. Room 1012F, Microwave into power strip.
3. Staff breakroom, Microwave into power strip
4. Mart storage, microwave into power strip.

During the exit conference on December 27, 2016 the above findings were again acknowledged by the Director of Plant Operations and Maintenance Technician.

The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.