HospitalInspections.org
Bringing transparency to federal inspections
HENDRICKS COMMUNITY HOSPITAL
Fire Alarm System - Out of Service
Tag No.: K0346
Based on a review of available documentation and staff interview, the facility failed to maintain an out of service plan for the fire alarm system per NFPA 101 (2012 edition), Life Safety Code, section 9.6.1.6. This deficient finding could have a isolated impact on the patients within the facility.
Findings include:
On 04/23/2024 at 12:10 PM, it was revealed by a review of available documentation that the current out of service policy for the fire alarm system states that a fire watch will be started when the fire alarm system is out of service for 10 hours instead of 4 hours.
An interview with the Maintenance Director verified this deficient finding at the time of discovery.