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Based on review of records the facility failed to provide an approved written emergency plan in accordance with the LSC section 18.7.1.1. This deficient practice could potentially affect all occupants of the facility in the event of staff not knowing their roles in emergency response.

Findings include:

On 8/27/13 between 10:20am and 11:20am during records review, the facility Fire Safety Plan was noted as being very fragmented with various duties and documents for each department. The overall Fire Safety Plan had not been updated to the new building. This condition was noted with the Environmental Services Supervisor present.

12/4/13 - The facility is finalizing the revisions to the Fire Safety Plan. The proposed plan was reviewed and found to be deficient in providing clear direction to staff regarding evacuation of smoke compartments. The plan is expected to be completed by 12/7/13 with training for all staff within 2 weeks.

Based on observation the facility failed to provide an approved fire alarm system in accordance with the LSC sections 18.3.4, 9.6. This deficient practice could potentially affect visitors and staff in the Main Entrance in the event of a fire not being contained by the 2-hour fire-rated occupancy separation.

Findings include:

On 8/27/13 at approximately 12:26pm, the following rooms were observed to have magnetic-type hold open devices for the doors without the required smoke detection for door release required by Section 7.2.1.8.2 of NFPA 101:
Financial Services 1248
Registration 1250
Registration 1251
This condition was noted with the Environmental Services Supervisor present.

12/4/13 - The smoke detectors are scheduled for installation during the week of 12/9/13. The facility expects the installation and inspection of the fire alarm devices to be completed within the month of December.