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Based on staff interview, not all emergency lighting is maintained in accordance with 7.9.

Findings include:

A. During an interview held in the CEO's Office at 10:30 AM on March 30, 2011, the provider's Plant Operations Manager stated that battery-powered emergency lights are not tested for a period of 1-1/2 hours at least once each year as required by 7.9.3. This deficiency could affect all patients in the 25 bed facility, as well as any staff and visitors present, because the failure of emergency lights could prevent those occupants from reaching an exit from the building.

Update 01/26/2012: The battery powered emergency lights testing are not properly documented.We shall be able to clear this tag during the Final follow up visit.

Based on document review and staff interview, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1. This deficiency could affect all patients in the 25 bed facility and all patients in the 5 Emergency Department Treatment Rooms, as well as any staff and visitors present, because the failure to maintain any of those components could result in smoke or fire passing from one part of the building to another.

Findings include:

A. During an interview held in the CEO's Office at 11:00 AM on March 29, 2011, the provider's Plant Operations Manager was not able to identify the locations of certain key building life safety components which comprise a portion of the facility's fire protection plan required by 19.7.1.1. During that interview, the Plant Operations Manager confirmed that no records of the locations of those life safety components were available. Critical building components, key building data, or elements of building fire protection systems which could not be properly identified include (but are not necessarily limited to):

1. Building construction types.

2. Occupancy classifications.

3. Portions of the building covered by an automatic sprinkler system.

4. Fire barriers and their fire resistance ratings, including occupancy separations, horizontal exits, building separations, and separations between disparate construction types.

5. Shaft enclosures and their fire resistance ratings, including exit stairs, exit discharge enclosures, elevators, or ventilation shafts. Surveyor 14290 notes that this includes the shaft for the Kitchen exhaust duct as it passes through the Second Floor.

6. Smoke barrier walls and areas (in square feet) of smoke compartments.

7. Exit access corridors and designated corridor walls.

8. The limits and areas (in square feet) of all suites.

9. Hazardous areas and their fire resistance ratings.

10. Exits.

11. Other special fire protection features such as areas of the building covered by a smoke evacuation system.

Update 01/26/2012: Based on review of the Life Safety drawings,and staff interview it was determined that the information identifying the locations of designated fire barriers for occupancy separations are inaccurate.

Based on document review and staff interview, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1. This deficiency could affect all patients in the 25 bed facility and all patients in the 5 Emergency Department Treatment Rooms, as well as any staff and visitors present, because the failure to maintain any of those components could result in smoke or fire passing from one part of the building to another.

Findings include:

A. During an interview held in the CEO's Office at 11:00 AM on March 29, 2011, the provider's Plant Operations Manager was not able to identify the locations of certain key building life safety components which comprise a portion of the facility's fire protection plan required by 19.7.1.1. During that interview, the Plant Operations Manager confirmed that no records of the locations of those life safety components were available. Critical building components, key building data, or elements of building fire protection systems which could not be properly identified include (but are not necessarily limited to):

1. Building construction types.

2. Occupancy classifications.

3. Portions of the building covered by an automatic sprinkler system.

4. Fire barriers and their fire resistance ratings, including occupancy separations, horizontal exits, building separations, and separations between disparate construction types.

5. Shaft enclosures and their fire resistance ratings, including exit stairs, exit discharge enclosures, elevators, or ventilation shafts. Surveyor 14290 notes that this includes the shaft for the Kitchen exhaust duct as it passes through the Second Floor.

6. Smoke barrier walls and areas (in square feet) of smoke compartments.

7. Exit access corridors and designated corridor walls.

8. The limits and areas (in square feet) of all suites.

9. Hazardous areas and their fire resistance ratings.

10. Exits.

11. Other special fire protection features such as areas of the building covered by a smoke evacuation system.

Update 01/26/2012: Based upon review of the facility's Life Safety Plan, the designated 2 hour fire separation shown on the plan are not accurately defined to match with the existing condition.

Based on document review, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2. This deficiency could affect all patients in the 25 bed facility and all patients in the 5 Emergency Department Treatment Rooms, as well as any staff and visitors present, because the failure to prepare to react in emergency conditions could result in the failure to execute the facility's fire plan.

Findings include:

A. Based on document review, fire drills are not conducted at varying times as required by 19.7.1.2. During the calendar years 2010 and 2011, fire drills for the following quarters/shifts were conducted at the similar times listed (all roughly between the hours of 1:00 PM and 3:30 PM, regardless of the shift involved):

1. First Shift:

a. First Quarter 2010: none performed.

b. Second Quarter 2010: April 5, 2010, 1:20 PM.

c. Third Quarter 2010: July 2, 2010, 3:17 PM.

d. Fourth Quarter 2010: October 12, 2010, 1:30 PM.

e. First Quarter 2011: January 10, 2011, 1:27 PM.

2. Second Shift:

a. First Quarter 2010: February 10, 2010, 3:28 PM.

b. Second Quarter 2010: May 4, 2010, 1:15 PM.

c. Third Quarter 2010: August 13, 2010, 2:00 PM.

d. Fourth Quarter 2010: November 5, 2010, 2:30 PM.

e. First Quarter 2011: February 4, 2011, 1:06 PM.

3. Third Shift:

a. First Quarter 2010: March 1, 2010, 2:57 PM.

b. Second Quarter 2010: June 2, 2010, 2:10 PM.

c. Third Quarter 2010: September 21, 2010, 2:00 PM.

d. Fourth Quarter 2010: December 7, 2010, 2:00 PM.

e. First Quarter 2011: March 7, 2011, 2:05 PM.

Update 01/26/2012: Fire Drill documentations shalll be reviewed during our Final Visit.

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Based on document review, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2. This deficiency could affect all patients in the 25 bed facility and all patients in the 5 Emergency Department Treatment Rooms, as well as any staff and visitors present, because the failure to prepare to react in emergency conditions could result in the failure to execute the facility's fire plan.

Findings include:

A. Based on document review, fire drills are not conducted at varying times as required by 19.7.1.2. During the calendar years 2010 and 2011, fire drills for the following quarters/shifts were conducted at the similar times listed (all roughly between the hours of 1:00 PM and 3:30 PM, regardless of the shift involved):

1. First Shift:

a. First Quarter 2010: none performed.

b. Second Quarter 2010: April 5, 2010, 1:20 PM.

c. Third Quarter 2010: July 2, 2010, 3:17 PM.

d. Fourth Quarter 2010: October 12, 2010, 1:30 PM.

e. First Quarter 2011: January 10, 2011, 1:27 PM.

2. Second Shift:

a. First Quarter 2010: February 10, 2010, 3:28 PM.

b. Second Quarter 2010: May 4, 2010, 1:15 PM.

c. Third Quarter 2010: August 13, 2010, 2:00 PM.

d. Fourth Quarter 2010: November 5, 2010, 2:30 PM.

e. First Quarter 2011: February 4, 2011, 1:06 PM.

3. Third Shift:

a. First Quarter 2010: March 1, 2010, 2:57 PM.

b. Second Quarter 2010: June 2, 2010, 2:10 PM.

c. Third Quarter 2010: September 21, 2010, 2:00 PM.

d. Fourth Quarter 2010: December 7, 2010, 2:00 PM.

e. First Quarter 2011: March 7, 2011, 2:05 PM.

Update 01/26/2012: Fire Drills documentations shall be reviewed on our Final Visit.

Based on document review and staff interview, the facility's fire alarm system is not inspected, tested, and maintained in accordance with 9.6. These deficiencies could affect all patients in the 25 bed facility and all patients in the 5 Emergency Department Treatment Rooms, as well as any staff and visitors present, because the failure to maintain the building fire alarm could result in the failure of the system to function in an emergency condition.

Findings include:

A. Through document review, it was determined that the facility does not visually inspect fire alarm system components on a periodic basis as required by NFPA 72 1999 Table 7-3.1. During an interview held in the CEO's Office at 11:05 AM on March 30, 2011, the provider's Plant Operations Manager confirmed this finding.

B. Through document review, it was determined that the facility does not test fire alarm system components on a periodic basis as required by NFPA 72 1999 Table 7-3.2. During an interview held in the CEO's Office at 11:05 AM on March 30, 2011, the provider's Plant Operations Manager confirmed this finding.

Update 01/26/2012: Testing results and maintenance records were not completely filled up to comply with NFPA 70 National Electric Code and NFPA 72.

A. Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

B. Corrected 01/26/2012.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

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Based on random observation during the survey walk-through, the facility's electrical system is not divided into the critical branch, life safety branch, and the equipment system as required by NFPA 99.

Findings include:

A. At 9:00 AM on March 30, 2011, The Emergency Department Addition's electrical system was observed to not be divided into the Emergency and and Equipment Systems as required by NFPA 99 1999 3-4.2.2.1. and NFPA 70 1999 517-30(b)(1), with the Emergency System not being further broken down into the Life Safety and Critical Branches as required by NFPA 99 1999 3-4.2.2.2. and NFPA 70 1999 517-30(b)(2). At the stated time and date, Panel E, located in the Emergency Department West Passage, was observed to serve both the Life Safety Branch and Critical electrical loads. This deficiency could affect all patients in the 5 Emergency Department Treatment Rooms, as well as any staff and visitors present, because the power sources for building life safety components such as exit signs and the fire alarm system are not protected.

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