HospitalInspections.org

Based upon a review of records and staff interview, the facility fails to assure that fire drills are held at unexpected times, under varying conditions and at least once per shift per quarter. This has the potential of affecting staff preparation and experience in providing for the protection of all residents, staff and visitors in the event of a fire, affecting 5 of 5 smoke zones. The facility has a capacity of 25 with a census of 12 at the time of the survey.

Findings include:

During the tour conducted on 07/16/2012, at approximately 4:00 p.m. a review of fire drill records since building occupancy in April 2012, revealed no documented monthly fire drills.

Maintenance Staff A and Administrative Staff A were present and acknowledged the results of the record review. Both facility staff stated that an all-staff training session is planned for the week following this survey, with drills for each shift to follow shortly thereafter.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

Based upon a review of records and staff interview, the facility fails to assure that the automatic sprinkler system is inspected, tested and maintained in accordance with NFPA 25. The deficient practice could result in the unexpected failure of the automatic fire sprinkler system, affecting 5 of 5 smoke zones. The facility has a capacity of 25 with a census of 12 at the time of the survey.

Findings include:

During the tour conducted on 07/16/2012, between 1:30 p.m. and 2:30 p.m., a review of records since building occupancy in April 2012, revealed the following:

-- 1. No documented quarterly testing of the automatic sprinkler system completed for the 2nd Qtr. 2012.

-- 2. No documented monthly visual inspections of the automatic sprinkler system from the date of occupancy through the time of this survey.

Maintenance Staff A was present and acknowledged the results of the records review. Maintenance Staff A stated that he was unaware of the requirements for monthly visual inspections and would begin the visual inspections and documentation thereof immediately. Maintenance Staff A stated that he would contact the sprinkler service company for assistance in quarterly testing of the sprinkler system.

NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1

NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1

Based upon a review of records and staff interview, the facility fails to assure that fire drills are held at unexpected times, under varying conditions and at least once per shift per quarter. This has the potential of affecting staff preparation and experience in providing for the protection of all residents, staff and visitors in the event of a fire, affecting 5 of 5 smoke zones. The facility has a capacity of 25 with a census of 12 at the time of the survey.

Findings include:

During the tour conducted on 07/16/2012, at approximately 4:00 p.m. a review of fire drill records since building occupancy in April 2012, revealed no documented monthly fire drills.

Maintenance Staff A and Administrative Staff A were present and acknowledged the results of the record review. Both facility staff stated that an all-staff training session is planned for the week following this survey, with drills for each shift to follow shortly thereafter.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

Based upon a review of records and staff interview, the facility fails to assure that the automatic sprinkler system is inspected, tested and maintained in accordance with NFPA 25. The deficient practice could result in the unexpected failure of the automatic fire sprinkler system, affecting 5 of 5 smoke zones. The facility has a capacity of 25 with a census of 12 at the time of the survey.

Findings include:

During the tour conducted on 07/16/2012, between 1:30 p.m. and 2:30 p.m., a review of records since building occupancy in April 2012, revealed the following:

-- 1. No documented quarterly testing of the automatic sprinkler system completed for the 2nd Qtr. 2012.

-- 2. No documented monthly visual inspections of the automatic sprinkler system from the date of occupancy through the time of this survey.

Maintenance Staff A was present and acknowledged the results of the records review. Maintenance Staff A stated that he was unaware of the requirements for monthly visual inspections and would begin the visual inspections and documentation thereof immediately. Maintenance Staff A stated that he would contact the sprinkler service company for assistance in quarterly testing of the sprinkler system.

NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1

NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1