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UNITY PSYCHIATRIC CARE - HUNTSVILLE
Exit Signage
Tag No.: K0293
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Based on observation, the facility failed to provide "No Exit" signage per the requirements of:
2012 NFPA 101, 19.2.10.1, and 7.10.8.3.2
This deficiency affects 1 of 2 smoke compartments.
Findings include:
On 09/14/2021, during a tour of the facility from 12:45 pm to 3:15 pm, the surveyor observed the door to the outside courtyard (that was not a means of egress) had signage above the door stating "no exit", but the letter size and arrangement did not meet code requirements.
A member of the maintenance staff was present when this deficiency was identified.
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Fire Alarm System - Initiation
Tag No.: K0342
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Based on observation, the facility failed to ensure a fire alarm manual pull station was accessible, unobstructed, and visible per the requirements of:
2012 NFPA 101, 19.3.4.2.1 and 9.6.2.7
This deficiency affects one of two smoke compartments.
Finding include:
On 09/14/2021, during a tour of the facility from 12:45 pm to 3:15 pm, the surveyor observed a fire alarm manual pull station in the Maintenance Shop was obstructed, unaccessible and not visible by a plastic milk crate, cardboard boxes and a plastic backpack sprayer laying on top of a portable workstation.
A member of the maintenance staff was present when this deficiency was identified.
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Corridors - Areas Open to Corridor
Tag No.: K0361
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Based on observation, the facility failed to maintain areas open to the corridor per the requirements of:
2012 NFPA 101, 19.3.6.1 (1) (c)
This deficiency affects 1 of 2 smoke compartments.
Findings include:
On 09/14/2021, during a tour of the facility from 12:45 pm to 3:15 pm, the surveyor observed the vending machine space was open to the corridor, and did not have an electrically supervised automatic smoke detection system. This space did not allow direct supervision by the facility staff from a Nurses' Station or similar space.
A member of the maintenance staff was present when this deficiency was identified.
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Corridor - Doors
Tag No.: K0363
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Based on observation, the facility failed to maintain the corridor doors per the requirements of:
2012 NFPA 101, 19.3.6.3.10
This deficiency affects 1 of 2 smoke compartments.
Findings include:
On 09/14/2021, during a tour of the facility from 12:45 pm to 3:15 pm, the surveyor observed the Outpatient Suite corridor door with a self-closing device was propped open with a wedge and the maintenance supervisor propped open the Maintenance Shop corridor door with self-closing device with a wedge while retrieving a ladder from the Maintenance Shop.
A member of the maintenance staff was present when this deficiency was identified.
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Smoking Regulations
Tag No.: K0741
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Based on documentation and observation, the facility failed to prohibit smoking on the facility's premises per the requirements of:
2012 NFPA 101, 19.7.4
This deficiency affects both smoke compartments.
Findings include:
On 09/14/2021, during a tour of the facility from 12:45 to 3:15 pm, the surveyor observed a staff member sitting on the concrete transformer pad (at the loading dock area) smoking and also observed discarded cigarette butts in this same area. Per documentatin provided by the facility "No Smoking on Facility Premises" is this facility's policy.
A member of the maintenance staff was present when this deficiency was identified.
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Gas Equipment - Cylinder and Container Storag
Tag No.: K0923
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Based on observation, the facility failed to provide an oxygen storage sign on door of the Oxygen Cylinder Storage Room per the requirements of:
2012 NFPA 99, 11.3.4.1, and 11.3.4.2
This deficiency affects 1 of 2 smoke compartments.
Findings include:
On 09/14/2021, during a tour of the facility from 12:45 pm to 3:15 pm, the surveyor observed the Oxygen Cylinder Storage Room did not have the following signage:
CAUTION:
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING
A member of the maintenance staff was present when this deficiency was identified.
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Features of Fire Protection - Other
Tag No.: K0932
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Based on observation, the facility failed to maintain the storage of LP Portable tanks per the requirements of:
2012 NFPA 99, 15.3.1(3) and 15.3.2
2011 NFPA 58, 8.2.1.3, 8.4.2, and Table 8.3.1 (a)
This deficiency affects 1 of 2 smoke compartments.
Findings include:
On 09/14/2021, during a tour of the facility from 12:45 am to 3:15 pm, the surveyor observed a 40 lb. portable propane tank connected to a gas grill being stored at the loading dock area.
A member of the maintenance staff was present when this deficiency was identified.