Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 530025 (X3) Date Survey Completed 11/07/2011
Name of Provider or Supplier Ivinson Memorial Hospital Street Address, City, State 255 N 30th, Laramie, WY
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
K0029 LIFE SAFETY CODE STANDARD
CFR(s): NFPA 101

One hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas are separated from other spaces by smoke resisting partitions and doors. Doors are self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1


This STANDARD is not met as evidenced by:
Based on observation and staff interview, the facility failed to ensure hazardous areas were separated from use areas on 2 of 3 floors. The findings were: 1. Observation of the microfiche storeroom on 11/3/11 at 10:55 AM showed the room measured 8 feet by 16 feet and had several shelves of microfiche and other stored items. Further review showed the corridor door was not equipped with a self-closing device. At the time of observation the facility supervisor reported he was unaware hazardous areas were required to have a self-closing device on corridor doors. 2. Observation of the laboratory information technology server room on 11/4/11 at 8:53 AM showed a halon suppression system had been installed. Further observation showed the entrance door was not equipped with a self-closing device and it could not be determined if the air-conditioning units would shut down with the activation of the system. At the time of observation the facility supervisor reported he was unaware of the aforementioned requirement. He also reported that the system was serviced semi-annually and the last testing report, 10/17/11, did not indicate all openings were required to be self-closing. Reference: 19.3.5.1, 9.7.3.1; NFPA 12A, 1997 Edition; 3-3.1.2 To prevent loss of agent through openings to adjacent hazards or work areas, openings shall be permanently sealed or equipped with automatic closures. Where reasonable confinement or agent is not practicable, protection shall be extended to include the adjacent connected hazards or work areas. 3-3.1.3 Forced-air ventilating systems including in-room air conditioning units shall be shut down or closed automatically where their continued operation would adversely affect the performance of the Halon 1301 system or result in propagation of the fire.