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ASPIRE HEALTH PARTNERS
No Description Available
Tag No.: K0048
Based on observation and staff interview, the facility failed to keep their required Fire Plan updated annually. NFPA 101 Ch. 19.7.1.1 specifies that, ' 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, ... ' Additionally, Ch. 19.7.2.2 ' A written health care occupancy fire safety plan shall provide for the following: (9) Extinguishment of fire. '
Findings include:
During the review of records, a request was made for documentation that would show that the Comprehensive Emergency Management Plan (CEMP), including the Fire Plan, had been reviewed and approved by the local AHJ. A current letter from Orange County Emergency Management was reviewed and found to be current. The Fire plan approval from the Orange County Fire Marshal was reviewed and it was discovered to have an approval date of January 14, 2012. Inquiry of staff revealed that the facility has a policy of obtaining an annual review of the CEMP and did not request a separate review and approval by the Fire Department for the fire plan.
These findings were reconfirmed with senior staff during the closing conference at 3:00 pm.
LIFE SAFETY CODE STANDARD
Tag No.: K0048
Based on observation and staff interview, the facility failed to keep their required Fire Plan updated annually. NFPA 101 Ch. 19.7.1.1 specifies that, ' 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, ... ' Additionally, Ch. 19.7.2.2 ' A written health care occupancy fire safety plan shall provide for the following: (9) Extinguishment of fire. '
Findings include:
During the review of records, a request was made for documentation that would show that the Comprehensive Emergency Management Plan (CEMP), including the Fire Plan, had been reviewed and approved by the local AHJ. A current letter from Orange County Emergency Management was reviewed and found to be current. The Fire plan approval from the Orange County Fire Marshal was reviewed and it was discovered to have an approval date of January 14, 2012. Inquiry of staff revealed that the facility has a policy of obtaining an annual review of the CEMP and did not request a separate review and approval by the Fire Department for the fire plan.
These findings were reconfirmed with senior staff during the closing conference at 3:00 pm.