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)
K0048 LIFE SAFETY CODE STANDARD
CFR(s): NFPA 101

There is a written plan for the protection of all patients and for their evacuation in the event of an emergency. 19.7.1.1


This STANDARD is not met as evidenced by:
Based on policy review and staff interview, the facility failed to ensure 2 of 8 policies were complete. The findings were: 1. Review of the smoking policy showed the policy did not indicate that "No Smoking" signs would be placed at all major entrances and no secondary signs would be posted where oxygen was in use, which was the facilities practice. Periodic observation on 11/3-7/11 showed none of the patient or treatment rooms where oxygen was used were posted with "No Smoking" signs. On 11/3/11 at 8:30 AM the chief financial officer (CFO) confirmed he was unaware the aforementioned language was required in the smoking policy. 2. Review of the smoking policy showed the policy did not indicate that ashtrays and metal self-closing containers to empty the ashtrays into would be supplied at all areas were smoking was permitted. On 11/3/11 at 8:30 AM the CFO confirmed he was unaware the aforementioned language was required in the smoking policy. 3. Review of the fire response (CODE RED) plan showed the policy did not address the evacuation of the smoke compartment of fire origin or evacuation of the floor and building. On 11/3/11 at 8:30 AM the CFO confirmed he was unaware the aforementioned language was required in the fire response policy. Reference: NFPA 101, 2000 Edition; 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following: (1) Use of alarms (2) Transmission of alarm to fire department (3) Response to alarms (4) Isolation of fire (5) Evacuation of immediate area (6) Evacuation of smoke compartment (7) Preparation of floors and building for evacuation (8) Extinguishment of fire 19.7.4* Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. (2) Smoking by patients classified as not responsible shall be prohibited. Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision. (3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.