Exits Not Sufficiently Resistant to Fire; Medical Records Stacked on the Floor

The Centers of Medicare and Medicaid Services (CMS) determined that Peachford Behavioral Health System of Atlanta did not meet the Medicare condition of participation for physical environment because “the facility failed to ensure that the hospital was constructed, arranged, and maintained to ensure the safety of patients and staff.”

CMS found that “all facility corridors and fire barriers have unprotected penetrations … caused by improper sealing of electrical wiring penetrations, and sheetrock construction failing to extend to structure.” The holes in the walls meant the facility failed to provide 1/2 hour fire resistance in exit corridors. Facility staff told CMS that they were made aware of the problem by violations in a previous survey by the Joint Commission, and had planned a future construction project to remedy the situation.

Additionally, CMS found that the facility failed to properly and securely store medical records as paper medical records were being stored on the floor in several areas of the medical records department. In an interview, the medical records supervisor stated “that with the increased patient admissions, it was becoming more difficult to store the medical records.”