Facility Manager Using Patient Triggered Alarms as Fire Drills Among Many Life Safety Code Violations

Wyoming Behavioral Institute in Casper, WY was cited by the Centers for Medicare and Medicaid Services (CMS) for deficiencies related to life safety code standards. The inspection revealed:
“facility staff was recording resident initiated fire alarms as staged fire drills. As a result, eight fire drills were not conducted during four previous quarters and during all shifts. Interview with the maintenance manager revealed he was unaware resident initiated fire alarms could not be counted as staged fire drills”
CMS found that the facility failed to ensure electrical wiring was in compliance with the National Electrical Code in 3 of 5 smoke compartments. CMS found the following areas that did not meet code: 1. Two wall mounted electrical outlets located in the adolescent exam room and in the class room were not ground fault circuit interrupter protected 2. An electrical box cover plate was cracked in the adolescent class room and an electrical box in a utility room in the adult wing was not firmly attached to the wall 3. A surge protector was plugged into another surge protector in a resident room, a classroom, and an intake assessment office 4. A surge protector was plugged into an electrical splicer in the other intake office. CMS also found five concerns that did not meet life safety codes including: 1. A 8” by 12” hole in the wall of a storage room 2. A 6” diameter hole in the wall of a resident room 3. Approximately 6 small holes in the staff room 4. A 1” gap in the ceiling and floor level of a vertical pipe used for drain testing in the basement 5. A 1” diameter hole in the ceiling of the file room CMS also found that the biannual inspection of the fire suppression system in the kitchen was not conducted. An interview with the maintenance manager “revealed the fire suppression system [in the kitchen] needed to be replaced.” CMS found other deficiencies related to the sprinkler heads that were not installed properly, emergency exit signs that were not fully illuminated, and cross corridor smoke barrier door that did not close completely because “it was kicked in by a resident recently.” In the plan of correction, the facility agreed to repair all deficiencies found by CMS. Also, the facility wrote that the Director of Physical Plant and the Lead Maintenance Tech are scheduled to attend Life Safety Code Training through UHS Corporate Facilities Management.