HospitalInspections.org

Based upon record review and staff interview, the facility is not conducting fire drills as required and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all residents, visitors and staff in 8 of 8 smoke zones. The facility has a capacity of 25 with a census of 3 at the time of this survey.

Findings include:

During the tour conducted on 03/15/18, between 9:00 a.m. and 10:00 a.m., a review of fire drill records for the last 5 quarters revealed the following:

-- 1. Fire drills held for the 2nd Shift for the 2nd and 3rd qtrs. of 2017 were held as silent (coded) drills at 6:35 a.m. and 6:55 a.m., respectively. The time frame for silent, coded drills is between 9:00 p.m. and 6:00 a.m. and the specified drills were outside of the permitted time frame.

Director of Engineering and Facilities Manager were present and acknowledged the results of the record review. Chief Executive Officer was made aware of the findings at the exit interview.

NFPA Standard: Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff (nurses, interns, maintenance engineers, and administrative staff) is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7

Based upon a review of records and staff interview the facility is not inspecting and maintaining fire-rated door assemblies in compliance with NFPA 80. This deficient practice could prevent the ability of the facility to properly confine smoke and prevent fire from spreading to other areas of the building. This deficient practice would affect all residents, visitors, and staff in 8 of 8 smoke zones. The facility has a capacity of 25 with a census of 3 at the time of this survey.

Findings include:

During the tour conducted on 03/15/18, at a review of records between 9:00 a.m. and 10:00 a.m., the following deficiency is noted:

-- 1. No documented training for qualification of personnel who test and maintain fire-rated door assemblies.

Director of Engineering and Facilities Manager were present and acknowledged the findings. Chief Executive Officer was made aware of the findings at the exit interview.

NFPA Standard: NFPA 80 2010 5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. 5.2.4.2 As a minimum, the following items shall be verified: (1) No open holes or breaks exist in the surfaces of either the door or frame. (2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. (3) The door, frame, hinges, hardware, and non combustible threshold are secured, aligned, and in working order with no visible signs of damage. (4) No parts are missing or broken. (5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7 (6) The self-closing device is operational; that is, the active door completely closes when operated from the open position. (7) If a coordinator is installed, the inactive leaf closes before the active leaf. (8) Latching hardware operates and secures the door when it is in the closed position. (9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame. (10) No field modifications to the door assembly have been performed that void the label. (11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity. 3.3.95 Qualified Person. A person who, by possession of a recognized degree, certificate, professional standing, or skill, and who by knowledge, training, and experience, has demonstrated the ability to deal with the subject matter, the work, or the project.