HospitalInspections.org

Based on record review and staff interview, the facility failed to provide a policy regarding the procedures to be taken in the event the fire alarm system is out of service for more than four hours in any twenty-four hour period in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 9.6.1.6. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 21 patients.

Findings include:

Record review and staff interview on 3/30/23 at 10:18 a.m., revealed the facility failed to include contact numbers in a fire alarm outage policy for authorities having jurisdiction, to include the State Fire Marshal, Iowa Department of Inspections and Appeals and the Knoxville Fire Department. Maintenance Staff verified record review during the survey process.

Based on observation and staff interview, this facility is not assuring that all smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.3.7.3. The facility has a capacity of 25 with a census of 8 patients.

Findings include:

Observation and staff interview on 3/30/23 at 11:34 a.m., revealed a penetration, (approximately 1/2 inch), around two white communications lines and one blue communications line, extending through the Infusion Center Smoke Barrier Wall. Maintenance Staff verified observations during the survey process.