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Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 19.19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On April 05, 2012 the surveyors, accompanied by the Director of Facilities, Director of Safety/Biomedical and Director of Therapy observed the following corridor doors would not tightly close when tested three of three times or were missing part of the door closure assembly or were not smoke resistant.

1. Room 208, 209 holes in the corridor doors

2. The following rooms either the door did not positively latch when tested three of three times or had the door closure arms removed from the door assembly:

1. Rooms, 207, 203, 228, 224
2. Social workers office
3. Nurses station AP-4
4. Group room by AP-4
5. Storage room door by AP-4 marked 2170
6. Room 2016 and 2199
7. AP-1. AP-3, AP-5, and Child Adolescents had missing or torn astragal's.
8. Adult Services door 2154 smoke seals torn

During the exit conference on April 05, 2012, the above findings were again acknowledged by the Chief Executive Officer, Director of Quality Risk and Education, Director of Facilities, Director of Safety/Biomedical and Director of Therapy.

In time of a fire, failing to protect patients from heat and smoke could cause harm to the patients.

Based on observation the facility failed to maintain self closing doors in a smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.7.3 or Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than I hour. (1/2 hour for existing) Section 8.3.4.1, " Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

Findings include:

On April 05, 2012 the surveyors, accompanied by the Director of Facilities, Director of Safety/Biomedical observed corridor smoke/fire doors marked 2150 adjacent to Quality Risk Education when closed there was an approximate three inch gap between the double doors.

During the exit conference on April 05, 2012, the above findings were again acknowledged by the Chief Executive Officer, Director of Quality Risk and Education, Director of Facilities, Director of Safety/Biomedical and Director of Therapy.

This installation will allow smoke to contaminate smoke zones not directly effected by the fire, which could cause harm to the patients.

Based on observation the facility did not keep the required signs posted at the exit doors equipped with special operating features and failed to maintain the special locking exit doors.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.1, " Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.2.1.6.1 (d) " On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in high and not less than 1/8 in. in stroke width on a contrasting background that reads as follows:

"PUSH UNTIL ALARM SOUNDS. DOOR CAN BE OPENED IN 15 SECONDS"

NFPA 101 Life Safety Court, 2000, Chapter 19, Section, 19.2.2.2.4 "Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side." Exception No. 2 "Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path. Section 7.2.1.6.1 "Special Locking Arrangements" " (c) An irreversible process shall release the lock within 15 to 30 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbf nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only."

Findings include:

On April 05, 2012 the surveyors, accompanied by the Director of Facilities, Director of Safety/ Biomedical and Director of Therapy observed AP-2, AP-3 and AP-4 the doors did not have signs mounted on or adjacent to the special locking exit doors One set of special locking exit doors by AP-3 would not open when tested three of three times.

During the exit conference on April 05, 2012, the above findings were again acknowledged by the Chief Executive Officer, Director of Quality Risk and Education, Director of Facilities, Director of Safety/ Biomedical and Director of Therapy.

Failing to provide manual release of the exit doors could cause harm to the patients and staff in an emergency. Failure to keep the signs posted could delay the exiting of patients during a fire or emergency.

'Based on observation the facility failed to maintain illuminated exit sign.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.10, Section 19.2.10.1 " Means of egress shall have signs in accordance with Section 7.10."Section 7.10.5.1, "Every sign required by 7.10.1.2 or 7.10.1.4 other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

Findings include:

On April 05, 2012 the surveyor, accompanied by Director of Safety/Biomedical observed the exit sign in the Main Gymnasium was not illuminated. It appears the bulbs were burnt out in the sign.

During the exit conference on April 05, 2012, the above findings were again acknowledged by the Chief Executive Officer, Director of Quality Risk and Education, Director of Facilities, Director of Safety/Biomedical and Director of Therapy.

Failing to maintain illuminated exit signs could cause harm to the patients.

K050 is a CONDITION OF PARTICIPATION

Based on Record Review, observations and staff interviews, the facility failed to conduct the required fire drills, failed to provide a written plan for the protection of all patients in time of a fire or emergency and train all staff on life safety procedures and devices.

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."

NFPA 101 Life Safety Code, 2000 Chapter 19, Section 19.7...1.3 Employees of Health Care occupancies shall be instructed in life safety procedures and devices.

Findings include:

On April 05, 2012 the surveyors, accompanied by the Director of Facilities, Director of Safety/Biomedical and Director of Therapy observed staff members at AP-1 though Ap-5 nurses stations. The surveyors requested the staff to locate a written fire and emergency policy manual at the nurses stations.The staff could not locate the written fire and emergency policy manual as requested by the surveyors. The staff advised the surveyors the written fire emergency manual policy was on the computer. The nurse stations had a Code Education Board posted at four of the five nurse stations. Staff members did not identify the Code Education Board for information for a fire located inside with the posted information.

The following facility personnel did not know the Fire Prevention Management Plan, dated January 2012 for the facility when asked by the surveyors. The detailed plan includes the terminology for RACE and PASS. The facilities staff have RACE and PASS on their ID badges and could not identify the acronym RACE and PASS:

1. Social services
2. Housekeeping
3. AP-1
4. AP-4

The fire drill documentation was inconsistent as documented in the following examples and contained post drill comments as quoted:

1. The fourth quarter fire drill for the first shift of 2011 was not found or documented

2. The fire drill dated March 30, 2011 for AP-3 and adjacent site AP-1 was a third shift fire drill. The form indicated in the Post Drill Critique Section, " Participating staff did not feel that fire drill was necessary " . They did not participated or take advantage of the Education from doing the drills. Staff members interviewed is unaware of Policy and Procedures during an actual fire.

The fire drill form on March 30, 2011 indicated in Section 1 Response Technique "The alarm was sounded"
Section 3 Associate Knowledge items one through 5 was marked NO." as indicated below:

1. Where is the evacuation plan located?
2. What equipment is used for evacuation?
3. What is your evacuation route for your area?
4. What is the Race Procedure?
5. What is PASSING?

Section 4 Drill Checklist

1. Staff located fire source and simulated extinguishing fire. "This was marked NO"

2. The fire drill dated March 19, 2012 for BHC Resource IOP and adjacent sites Momentum/AP-5 First Shift, 1. Section 1 Fire response Techniques,

"Fire alarm activation was marked YES" Section 1, "Section 4 Drill Checklist staff located fire source and simulated extinguishing fire. This was marked NO"

3. The Section marked Fire Protection Systems Item 1. "Alarm systems, bells and lights functioned properly was marked NO"

4."AP-5 and Momentum the Monitors remarks and post drill critique issues indicated Heard Code Red Loud and Clear"

During the exit conference on April 05, 2012, the above findings were again acknowledged by the Chief Executive Officer, Director of Quality, Risk and Education, Director of facilities, Director of Safety/ Biomedical and Director of Therapy.

In time of a fire or emergency, an emergency policy manual must be readily available for the staff. Patients could be harmed if the Staff is not trained or is unable to locate the emergency evacuation policy manual. Failure to train and drill the staff on fire procedures could result in harm to the patients.

Based on observation the facility failed to keep automatic sprinkler heads free of lint and paint and the facility did not assure that all parts of the sprinkler system were in accordance with the UL Listing.

NFPA 101, Life Safety Code, 2000 Edition, Chapter 19, Section 19.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved supervised automatic sprinkler system in accordance with 9.7." Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13, Standard for the installation of Sprinkler Systems." NFPA 13, Chapter 12, Section 12-1 "General" "A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25....NFPA 25, Chapter 2, Section 2-2.1 "Sprinklers" 2-2.1.1 ...Sprinklers shall be free of corrosion, foreign material, paint, and physical damage and shall be installed in the proper orientation (e.g.,upright, pendant, or sidewall). " Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

Findings Include:

On April 05, 2012, the surveyors accompanied by the Director of Facilities, Director of Safety/ Biomedical and Director of Therapy observed the following rooms had either lint or paint or were missing the escutcheon plates from the sprinkler assembly.

1. Rooms 202, three of three lint
2. Dayroom in AP-2 six with lint or paint
3. Mens bathroom main entrance lint one
4. Rooms 208, 209 paint one of two or three
5. Adjacent to rooms 125 and 126 lint on two of three sprinklers
6. Room 243 two of three lint
7. Room 245 one of four lint
8. AP-1 shower room one corroded sprinkler.
9. Escutcheon plates missing AP-2 Group Room one of two
10. Adjacent to door number 2016
11. AP-5 in the Clean Utility

During the exit conference on April 05, 2012, the above findings were again acknowledged by the Chief Executive Officer, Director of Quality, Risk and Education, Director of Facilities, Director of Safety/Biomed and Director of Therapy.

Sprinkler heads are U.L. listed to respond to a calculated ceiling temperature. Paint and lint on the head could slow that response or disable the sprinkler head. Missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, will allow heat and smoke to effect other areas of the building. Failure to maintain the sprinkler heads could result in a malfunction during a fire. This could cause harm to the patients.

Based on Observation and staff interview the facility failed to follow the smoking policy for designated smoking areas for the facility.

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 (4) "Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted."

Findings include:

On April 05, 2012 the surveyor accompanied by the Director of Director of Facilities, Director of Safety/Biomedical observed the AP-1 Staff Patio had cigarette butts being disposed of in a plastic trash container. The area did not have a self closing metal container and upon conversation with the staff this is not a designated smoking location. Further review of the facility smoking policy does not indicate this is a designated smoking location for staff or patients.

During the exit conference on April 05, 2012, the above findings were again acknowledged by the Chief Executive Officer, Director of Quality, Risk and Education, Director of Facilities, Director of Safety/Biomedical and Director of Therapy.

Failure to follow the facility smoking policy and dispose cigarette butts in proper containers could result in a fire which could cause harm to patients.

Based on observation the facility failed to mount receptacle outlets five feet above the floor in the oxygen storage rooms.

NFPA 101 Life Safety Code, Chapter 19, Section 19.3.2.4 " Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 Chapter 8, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage.

Findings include:

On April 05, 2012 the surveyor, accompanied by the Director of Therapy observed the wall mounted receptacle outlets in the oxygen storage rooms. The oxygen cylinders were being stored next to the wall receptacle outlets.

1. AP-1 examine room four cylinders
2. Ap-3 storage room three cylinders
3. Child Adolescent examine room two cylinders.
.
During the exit conference on April 05, 2012, the above findings were again acknowledged by the Chief Executive Officer, Director of Quality Risk and Education, Director of Facilities, Director of Safety/Biomedical and Director Of Therapy.

Failing to mount receptacle outlets five feet above the floor to prevent an accident/or possible fire could cause harm to the patients.

Based on Observation the facility allowed the use of a multiple outlet adapters, power strips and did not use the wall outlet receptacles for appliances.

NFPA 101, Life Safety Code, 2000, 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, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) 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 April 05, 2012 the Director of Safety/Biomedical observed a refrigerator in room 241 breakroom was plugged into multi-outlet power strip and not directly plugged in to the wall outlet receptacle.

During the exit conference on April 05, 2012, the above findings were again acknowledged by the Chief Executive Officer, Director of Quality, Risk and Education, Director of Facilities, Director of Safety/Biomedical and Director of Therapy.

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.

Based on Observation the facility failed to allow access to the electrical equipment/panel.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1., Section 9.1.2 "Electrical wiring and equipment shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions.

"(NO STORAGE ALLOWED IN THE WORKING SPACE)"

Findings include:

On April 05, 2012 the surveyor, accompanied by Director of Therapy observed storage in front of the electrical panel located in the AP-1 storage room marked door number 1142. The Child Services electrical panel LE-3 was not secured to the main electrical panel box it was missing three screws in the panel.

During the exit conference on April 05, 2012, the above findings were again acknowledged by the Chief Executive Officer, Director of Quality, Risk and Education, Director of Facilities, Director of Safety /Biomedical and Director of Therapy.

Blocking of access to electrical panels or equipment may delay personnel from controlling an emergency situation. Patients will be harmed if a fire should start because of a delay.

Based on Observation the facility failed to secure an electrical receptacle to the wall.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1 "Utilities shall comply with the provisions of Section 9.1." Section 9.1.2. "Electrical wiring and equipment installed shall be in accordance with NFPA 70 National Electrical Code. " NEC, Article 410, Section 410-56 (f) Receptacle Mounting
(2) "Receptacles mounted in boxes that are flush with the wall surface or project therefrom shall be installed so that the mounting yoke or strap of the receptacle is seated against the box or raised box cover."

Findings include:

On April 05, 2012 the surveyors, accompanied by the Director of Facilities, Director of Safety/Biomedical and Director of Therapy observed the following:

1. The electrical receptacle was not mounted and was hanging from the wall in the main entrance lobby.
2. AP-4 had a broken and loose receptacle outlet
3. AP-3 room 249 loose receptacle outlet
4. AP-2 by the laundry room had a burnt 110 receptacle outlet
5. AP-2 nurses station had a loose receptacle outlet.
5. The Financial Counselor office a loose receptacle outlet

During the exit conference on April 05, 2012, the above findings were again acknowledged by the Chief Executive Officer, Director of Quality, Risk and Education, Director of Facilities, Director of Safety/Biomedical and Director of Therapy.

Failing to secure electrical receptacles could cause electrical shocks or cause a fire. A fire could cause harm to the patients.

Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 19.19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On April 05, 2012 the surveyors, accompanied by the Director of Facilities, Director of Safety/Biomedical and Director of Therapy observed the following corridor doors would not tightly close when tested three of three times or were missing part of the door closure assembly or were not smoke resistant.

1. Room 208, 209 holes in the corridor doors

2. The following rooms either the door did not positively latch when tested three of three times or had the door closure arms removed from the door assembly:

1. Rooms, 207, 203, 228, 224
2. Social workers office
3. Nurses station AP-4
4. Group room by AP-4
5. Storage room door by AP-4 marked 2170
6. Room 2016 and 2199
7. AP-1. AP-3, AP-5, and Child Adolescents had missing or torn astragal's.
8. Adult Services door 2154 smoke seals torn

During the exit conference on April 05, 2012, the above findings were again acknowledged by the Chief Executive Officer, Director of Quality Risk and Education, Director of Facilities, Director of Safety/Biomedical and Director of Therapy.

In time of a fire, failing to protect patients from heat and smoke could cause harm to the patients.

Based on observation the facility failed to maintain self closing doors in a smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.7.3 or Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than I hour. (1/2 hour for existing) Section 8.3.4.1, " Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

Findings include:

On April 05, 2012 the surveyors, accompanied by the Director of Facilities, Director of Safety/Biomedical observed corridor smoke/fire doors marked 2150 adjacent to Quality Risk Education when closed there was an approximate three inch gap between the double doors.

During the exit conference on April 05, 2012, the above findings were again acknowledged by the Chief Executive Officer, Director of Quality Risk and Education, Director of Facilities, Director of Safety/Biomedical and Director of Therapy.

This installation will allow smoke to contaminate smoke zones not directly effected by the fire, which could cause harm to the patients.

Based on observation the facility did not keep the required signs posted at the exit doors equipped with special operating features and failed to maintain the special locking exit doors.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.1, " Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.2.1.6.1 (d) " On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in high and not less than 1/8 in. in stroke width on a contrasting background that reads as follows:

"PUSH UNTIL ALARM SOUNDS. DOOR CAN BE OPENED IN 15 SECONDS"

NFPA 101 Life Safety Court, 2000, Chapter 19, Section, 19.2.2.2.4 "Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side." Exception No. 2 "Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path. Section 7.2.1.6.1 "Special Locking Arrangements" " (c) An irreversible process shall release the lock within 15 to 30 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbf nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only."

Findings include:

On April 05, 2012 the surveyors, accompanied by the Director of Facilities, Director of Safety/ Biomedical and Director of Therapy observed AP-2, AP-3 and AP-4 the doors did not have signs mounted on or adjacent to the special locking exit doors One set of special locking exit doors by AP-3 would not open when tested three of three times.

During the exit conference on April 05, 2012, the above findings were again acknowledged by the Chief Executive Officer, Director of Quality Risk and Education, Director of Facilities, Director of Safety/ Biomedical and Director of Therapy.

Failing to provide manual release of the exit doors could cause harm to the patients and staff in an emergency. Failure to keep the signs posted could delay the exiting of patients during a fire or emergency.

'Based on observation the facility failed to maintain illuminated exit sign.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.10, Section 19.2.10.1 " Means of egress shall have signs in accordance with Section 7.10."Section 7.10.5.1, "Every sign required by 7.10.1.2 or 7.10.1.4 other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

Findings include:

On April 05, 2012 the surveyor, accompanied by Director of Safety/Biomedical observed the exit sign in the Main Gymnasium was not illuminated. It appears the bulbs were burnt out in the sign.

During the exit conference on April 05, 2012, the above findings were again acknowledged by the Chief Executive Officer, Director of Quality Risk and Education, Director of Facilities, Director of Safety/Biomedical and Director of Therapy.

Failing to maintain illuminated exit signs could cause harm to the patients.

K050 is a CONDITION OF PARTICIPATION

Based on Record Review, observations and staff interviews, the facility failed to conduct the required fire drills, failed to provide a written plan for the protection of all patients in time of a fire or emergency and train all staff on life safety procedures and devices.

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."

NFPA 101 Life Safety Code, 2000 Chapter 19, Section 19.7...1.3 Employees of Health Care occupancies shall be instructed in life safety procedures and devices.

Findings include:

On April 05, 2012 the surveyors, accompanied by the Director of Facilities, Director of Safety/Biomedical and Director of Therapy observed staff members at AP-1 though Ap-5 nurses stations. The surveyors requested the staff to locate a written fire and emergency policy manual at the nurses stations.The staff could not locate the written fire and emergency policy manual as requested by the surveyors. The staff advised the surveyors the written fire emergency manual policy was on the computer. The nurse stations had a Code Education Board posted at four of the five nurse stations. Staff members did not identify the Code Education Board for information for a fire located inside with the posted information.

The following facility personnel did not know the Fire Prevention Management Plan, dated January 2012 for the facility when asked by the surveyors. The detailed plan includes the terminology for RACE and PASS. The facilities staff have RACE and PASS on their ID badges and could not identify the acronym RACE and PASS:

1. Social services
2. Housekeeping
3. AP-1
4. AP-4

The fire drill documentation was inconsistent as documented in the following examples and contained post drill comments as quoted:

1. The fourth quarter fire drill for the first shift of 2011 was not found or documented

2. The fire drill dated March 30, 2011 for AP-3 and adjacent site AP-1 was a third shift fire drill. The form indicated in the Post Drill Critique Section, " Participating staff did not feel that fire drill was necessary " . They did not participated or take advantage of the Education from doing the drills. Staff members interviewed is unaware of Policy and Procedures during an actual fire.

The fire drill form on March 30, 2011 indicated in Section 1 Response Technique "The alarm was sounded"
Section 3 Associate Knowledge items one through 5 was marked NO." as indicated below:

1. Where is the evacuation plan located?
2. What equipment is used for evacuation?
3. What is your evacuation route for your area?
4. What is the Race Procedure?
5. What is PASSING?

Section 4 Drill Checklist

1. Staff located fire source and simulated extinguishing fire. "This was marked NO"

2. The fire drill dated March 19, 2012 for BHC Resource IOP and adjacent sites Momentum/AP-5 First Shift, 1. Section 1 Fire response Techniques,

"Fire alarm activation was marked YES" Section 1, "Section 4 Drill Checklist staff located fire source and simulated extinguishing fire. This was marked NO"

3. The Section marked Fire Protection Systems Item 1. "Alarm systems, bells and lights functioned properly was marked NO"

4."AP-5 and Momentum the Monitors remarks and post drill critique issues indicated Heard Code Red Loud and Clear"

During the exit conference on April 05, 2012, the above findings were again acknowledged by the Chief Executive Officer, Director of Quality, Risk and Education, Director of facilities, Director of Safety/ Biomedical and Director of Therapy.

In time of a fire or emergency, an emergency policy manual must be readily available for the staff. Patients could be harmed if the Staff is not trained or is unable to locate the emergency evacuation policy manual. Failure to train and drill the staff on fire procedures could result in harm to the patients.

Based on observation the facility failed to keep automatic sprinkler heads free of lint and paint and the facility did not assure that all parts of the sprinkler system were in accordance with the UL Listing.

NFPA 101, Life Safety Code, 2000 Edition, Chapter 19, Section 19.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved supervised automatic sprinkler system in accordance with 9.7." Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13, Standard for the installation of Sprinkler Systems." NFPA 13, Chapter 12, Section 12-1 "General" "A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25....NFPA 25, Chapter 2, Section 2-2.1 "Sprinklers" 2-2.1.1 ...Sprinklers shall be free of corrosion, foreign material, paint, and physical damage and shall be installed in the proper orientation (e.g.,upright, pendant, or sidewall). " Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

Findings Include:

On April 05, 2012, the surveyors accompanied by the Director of Facilities, Director of Safety/ Biomedical and Director of Therapy observed the following rooms had either lint or paint or were missing the escutcheon plates from the sprinkler assembly.

1. Rooms 202, three of three lint
2. Dayroom in AP-2 six with lint or paint
3. Mens bathroom main entrance lint one
4. Rooms 208, 209 paint one of two or three
5. Adjacent to rooms 125 and 126 lint on two of three sprinklers
6. Room 243 two of three lint
7. Room 245 one of four lint
8. AP-1 shower room one corroded sprinkler.
9. Escutcheon plates missing AP-2 Group Room one of two
10. Adjacent to door number 2016
11. AP-5 in the Clean Utility

During the exit conference on April 05, 2012, the above findings were again acknowledged by the Chief Executive Officer, Director of Quality, Risk and Education, Director of Facilities, Director of Safety/Biomed and Director of Therapy.

Sprinkler heads are U.L. listed to respond to a calculated ceiling temperature. Paint and lint on the head could slow that response or disable the sprinkler head. Missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, will allow heat and smoke to effect other areas of the building. Failure to maintain the sprinkler heads could result in a malfunction during a fire. This could cause harm to the patients.

Based on Observation and staff interview the facility failed to follow the smoking policy for designated smoking areas for the facility.

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 (4) "Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted."

Findings include:

On April 05, 2012 the surveyor accompanied by the Director of Director of Facilities, Director of Safety/Biomedical observed the AP-1 Staff Patio had cigarette butts being disposed of in a plastic trash container. The area did not have a self closing metal container and upon conversation with the staff this is not a designated smoking location. Further review of the facility smoking policy does not indicate this is a designated smoking location for staff or patients.

During the exit conference on April 05, 2012, the above findings were again acknowledged by the Chief Executive Officer, Director of Quality, Risk and Education, Director of Facilities, Director of Safety/Biomedical and Director of Therapy.

Failure to follow the facility smoking policy and dispose cigarette butts in proper containers could result in a fire which could cause harm to patients.

Based on observation the facility failed to mount receptacle outlets five feet above the floor in the oxygen storage rooms.

NFPA 101 Life Safety Code, Chapter 19, Section 19.3.2.4 " Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 Chapter 8, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage.

Findings include:

On April 05, 2012 the surveyor, accompanied by the Director of Therapy observed the wall mounted receptacle outlets in the oxygen storage rooms. The oxygen cylinders were being stored next to the wall receptacle outlets.

1. AP-1 examine room four cylinders
2. Ap-3 storage room three cylinders
3. Child Adolescent examine room two cylinders.
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During the exit conference on April 05, 2012, the above findings were again acknowledged by the Chief Executive Officer, Director of Quality Risk and Education, Director of Facilities, Director of Safety/Biomedical and Director Of Therapy.

Failing to mount receptacle outlets five feet above the floor to prevent an accident/or possible fire could cause harm to the patients.

Based on Observation the facility allowed the use of a multiple outlet adapters, power strips and did not use the wall outlet receptacles for appliances.

NFPA 101, Life Safety Code, 2000, 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, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) 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 April 05, 2012 the Director of Safety/Biomedical observed a refrigerator in room 241 breakroom was plugged into multi-outlet power strip and not directly plugged in to the wall outlet receptacle.

During the exit conference on April 05, 2012, the above findings were again acknowledged by the Chief Executive Officer, Director of Quality, Risk and Education, Director of Facilities, Director of Safety/Biomedical and Director of Therapy.

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.

Based on Observation the facility failed to allow access to the electrical equipment/panel.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1., Section 9.1.2 "Electrical wiring and equipment shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions.

"(NO STORAGE ALLOWED IN THE WORKING SPACE)"

Findings include:

On April 05, 2012 the surveyor, accompanied by Director of Therapy observed storage in front of the electrical panel located in the AP-1 storage room marked door number 1142. The Child Services electrical panel LE-3 was not secured to the main electrical panel box it was missing three screws in the panel.

During the exit conference on April 05, 2012, the above findings were again acknowledged by the Chief Executive Officer, Director of Quality, Risk and Education, Director of Facilities, Director of Safety /Biomedical and Director of Therapy.

Blocking of access to electrical panels or equipment may delay personnel from controlling an emergency situation. Patients will be harmed if a fire should start because of a delay.

Based on Observation the facility failed to secure an electrical receptacle to the wall.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1 "Utilities shall comply with the provisions of Section 9.1." Section 9.1.2. "Electrical wiring and equipment installed shall be in accordance with NFPA 70 National Electrical Code. " NEC, Article 410, Section 410-56 (f) Receptacle Mounting
(2) "Receptacles mounted in boxes that are flush with the wall surface or project therefrom shall be installed so that the mounting yoke or strap of the receptacle is seated against the box or raised box cover."

Findings include:

On April 05, 2012 the surveyors, accompanied by the Director of Facilities, Director of Safety/Biomedical and Director of Therapy observed the following:

1. The electrical receptacle was not mounted and was hanging from the wall in the main entrance lobby.
2. AP-4 had a broken and loose receptacle outlet
3. AP-3 room 249 loose receptacle outlet
4. AP-2 by the laundry room had a burnt 110 receptacle outlet
5. AP-2 nurses station had a loose receptacle outlet.
5. The Financial Counselor office a loose receptacle outlet

During the exit conference on April 05, 2012, the above findings were again acknowledged by the Chief Executive Officer, Director of Quality, Risk and Education, Director of Facilities, Director of Safety/Biomedical and Director of Therapy.

Failing to secure electrical receptacles could cause electrical shocks or cause a fire. A fire could cause harm to the patients.