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GREENE COUNTY HOSPITAL CAH
Means of Egress - General
Tag No.: K0211
Based on observations, the facility failed to inspect and test fire door assemblies in accordance with the CMS S&C letter 17-38-LSC, NFPA 101 section 7.2.1.15. This standard deficiency affected entire facility on the day of survey.
Findings include:
On 1/11/22 at 2:38 PM, the facility was unable to produce documentation showing annual inspection and testing of the eleven (11) fire doors in the facility.
The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 1/11/22.
Discharge from Exits
Tag No.: K0271
Based on observation, the facility failed to properly arrange exit discharge in accordance with NFPA 101 sections 19.2.7 & 7.7.2. These deficiencies practice affected entire facility on day of survey.
Findings include:
On 1/11/22 at 1:30 PM, observation revealed the required exit near Physical Therapy Area was blocked workout therapy equipment and did not discharge right of way to area of refuge (ex ...sidewalk leading to a parking lot).
The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 1/11/22.