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Based on record review and interview, the hospital failed to ensure development, maintenance, and annual review of a facility-based community-based risk assessment using an all hazards approach as required.

Findings:

Record review of the emergency preparedness plan showed the facility did not annually maintain and review the facility-based and community-based risk assessments that utilized an all hazards approach. An annual review for risk assessment for the facility emergency preparedness plan did not exist for 2018.

On 08/05/19 at 11:17 am, the surveyor asked Staff D for written documentation of the facility's risk assessments and associated emergency preparedness strategies. The surveyor also requested the annual approval meeting minutes. Staff D stated the risk assessment has been created and would be going for annual review soon.

Based on record review and interview the facility failed to ensure policy and procedures were established to address the use of volunteers in an emergency.

Findings:

Record review of the facility's Emergency Preparedness plan showed that they lacked a policy regarding the use of volunteers in an disaster. The policy did not exist.

On 08/06/19 at 1:38 PM, the surveyor requested documentation for policy and procedures for volunteers. Staff D stated the facility is in process of updating and revising policies to ensure compliance.

Based on record review and staff interview, the facility failed to ensure the emergency preparedness policies and procedures addressed the role of the facility under the 1135 waiver declared by the president in accordance with section 1135 of the act in provision of care and treatment.

Findings:

Record review of the facility's Emergency Preparedness plan showed that they lacked a policy regarding the facility's roles under a 1135 waiver during a declared disaster. The facility laced a policy.


On 08/05/19 at 10:50 am, the surveyor asked Staff D if the facility established policy and procedures addressing coordination efforts during a declared emergency in which a waiver of federal requirements under section 1135 of the Act has been granted by the Secretary. Staff D stated the facility is in process of updating policies to ensure compliance. The document did not exist.

Based on record review and interview, the facility failed to ensure review and annual update of the facility emergency preparedness communication plan.

Findings:

Record review of the emergency preparedness communication plan showed no facility documentation that the communication plan had been updated and reviewed annually for 2018.

On 08/06/19 at 11:17 am, the surveyor asked Staff D for documentation that the communication plan had been reviewed and approved annually. Staff D stated the communication plan annual approval did not exist.

Based on record review and interview the facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.

Findings:

Record review showed the facility's communications equipment or communication systems was not listed in the emergency plan.

On 08/06/19 at 2:26 pm, the surveyor asked Staff D what alternate means of communicating with staff, Federal, State, tribal, regional, and local emergency management agencies. Staff D stated the facility did have alternate means of communicating with staff and the facility was in the process of revising and updating the emergency plan to include the communication plan and means of communicating with both staff, tribal, local, federal and regional agencies.

Based on record review and interview, the facility failed to develop and maintain an emergency preparedness communication plan that addressed the means in the event of an evacuation, to release patient information to include the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4).

Findings:

Record review of the facility emergency preparedness communication plan did not contain methods for sharing information and medical documentation for patients under the facility's care with other health care providers to maintain continuity of care in the event of an evacuation as required.

On 08/06/19 at 11:33 am the surveyor asked Staff D for documentation to verify the facility had developed an emergency preparedness communication plan. The communication plan should include how the facility would share information for patients under the facility's care as necessary with other heath care providers in the event of an emergency. Staff D stated the facility would develop a plan to address sharing information in the event of an evacuation.

Based on record review and interview the facility failed to ensure annual and initial in-service training for staff, and individuals providing services under arrangement, on the emergency preparedness plan for 23 of 23 employee files.

Findings:

Record review of the facility emergency preparedness training documentation did not show the annual and initial in-service training for existing staff, and individuals providing services under arrangement

On 08/05/19 at 1:47 pm the surveyor asked Staff S for documentation of the training in-service for facility staff/volunteers and individuals providing services under contract and gave her a sample list of 23 facility employees to pull their training records for emergency preparedness in-service training.

On 08/06/19 at 11:43 am, the surveyor was provided with files for emergency preparedness staff training documentation requested. Staff S stated they did not have documentation showing the staff were trained on the facility's emergency preparedness plan as per the communication plan, risk assessment they have not done it. The facility training was based on NIMS training. The emergency preparedness in-service training does not exist for 23 of 23 sample of employee training files for 2018.

Based on observation and interview the facility failed to ensure aisles, passageways, corridors, exit discharges, exit locations, accesses, and the means of egress are continuously maintained free of all obstructions to full use in case of emergency.

Findings:

On 08/06/19 at 3:46 pm the surveyor observed an gurney located in the back hallway of the exit access corridor was up against wall and the and the means of egress was partially blocked.

On 08/06/19 at 3:47 pm, the surveyor asked Staff D if the gurney was always stored in the back hallway, Staff D stated the facility would need to find another location to store the gurney.

Based on observation and interview the facility failed to ensure barrel latches were not installed within the facility and to have on all exit access doors a positive latching locking device which opens with only one action.

Findings:

On 08/06/19 at 5:19 pm while on tour the surveyor observed a barrel latch's in the phlebotomy room, kitchen, and the Occupational Therapy bathroom as well as a padlock on the door in the activity area for patients. Staff D stated maintenance would follow-up and take barrel latches out.

Based on observation and interview the facility failed to ensure fire extinguishers located in the kitchen had placard(s) displayed next to each one as required.

Findings:

On 08/05/19 at am one ABC class fire extinguisher was observed in the kitchen with no placard posted next to them to indicate the hood fire protection system shall be activated prior to using the fire extinguisher as required.

On 08/05/19 at am, the surveyor Staff D stated they would get the appropriate placard for the fire extinguisher which was installed within the kitchen.


NFPA 96, 2011 Edition
Chapter 10 Fire Extinguishing Equipment
10.2 Types of Equipment
10.2.2* A placard shall be conspicuously placed near each extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.

Based on record review and interview the facility failed to provide a annual fire alarm system inspection that is required for life safety and is tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72.

Findings:


The facility had an annual inspection in June of 2018, however the current annual inspection is 2 months past due. The June 2018 report showed detectors and horn strobes needed service. Fire Alarm Systems shall be tested in accordance with NFPA.

On 08/06/19 at 3:43 pm, surveyor requested Staff D for the follow-up report and invoice to reflect the issues of 4 detectors are out of sensitivity settings and not all horn strobes sync as noted on the June 2018 inspection report. The invoice report received did not show if the horn strobes were synced. The report also did not show of an acceptance test and inspection was completed. Staff D stated the inspection was being scheduled.

Based on record review and interview and record review the facility failed to maintain their sprinkler system in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems as required.

Findings:

On 8/06/19 at pm, record review showed the facility fire sprinkler system to be yellow tagged by the Accurate Fire Equipment Co Inc on 5/9/19. The following impairments were identified in the inspection report: Gauges more than 5 years old, Dry system needs 5 year internal inspection performed, Wet system needs 5 year internal inspection performed and 5 corroded chrome escutcheons in the main hospital on Wet system.

On 8/06/19 Staff D was asked if the work has been completed which was outlined on the Accurate Fire Equipment Co Inc inspection report and Staff D stated they are getting the vendor to schedule the repairs.

Based on observation and interview the facility failed to ensure smoke barriers were smoke resistant.

Findings:

On 08/05/19 at 10:25 am, three penetration were observed in the ceiling of the CAT Scan room.

On 08/05/19 at 02:45 pm, penetrations were observed in the ceiling tiles located in the janitor closet in the kitchen.

On 08/06/19 at 04:57 pm, penetrations were observed in the wall of the mechanical room housing the boiler.

On 08/06/19 at 05:15 pm, penetrations were observed in radiology area.

On 08/06/19 at 05:16 pm, one ceiling tile were observed to be out of place in telephone room area.

On 08/06/19 at 5:17 pm the surveyor asked Staff D why the penetrations are not filled throughout the facility. Staff D stated she is getting maintenance to schedules setup to which a penetration preventative maintenance program will be followed up on.

Based on record review and interview the facility failed to include the transmission of a fire alarm signal on each fire drill.

Findings:

Record review showed facility fire drills for 2018, and 2019 did not document transmissions of fire alarm signals for every fire drill completed.

On 08/06/19 at 2:17 pm, the surveyor stated to Staff R each of the facility's fire alarm drills should include documentation of a transmission of a fire alarm signal for each individual fire drill. Staff R stated they would add that to each of the facility's fire drill documentation.

Based on record review and interview the facility failed to ensure the annual fire rated door assembly annual inspections were completed.

Findings:

Record review for the facility showed the annual fire rated door assembly inspections for 2018 were not completed and the documentation did not exist.

On 08/05/19 at 10:49 am the surveyor asked staff D for the annual fire rated door assembly inspections for the facility. Staff D stated the inspections were not completed and the documentation does not exist for 2018.

Based on record review and interview the facility failed to ensure the building system risk assessments were completed.

Findings:

Record review showed the facility EES (Essential Electrical System) and Medical Gas building system risk assessment were not completed. They do not exist.

On 08/05/19 at 11:13 am the surveyor asked Staff D for the EES and Medical Gas building system risk assessments. Staff D stated that they are not familiar with the requirement but will complete it now that they are aware.

Based on record review, and interview the facility failed to ensure annual impedance testing of patient care related electrical receptacles as required.

Findings:

Record review showed the facility did not have a patient care area impedence and receptacle testing program for existing, new receptacles and power service supply for patient care areas.

On 08/05/19 at 2:23 pm the surveyor asked staff D for the impedance testing inspection of patient care related electrical receptacles for patient care areas. Staff D stated they have not completed the testing but will get it scheduled as soon as possible. The documentation did not exist.

Based on record review and interview the facility failed to ensure 30 minute load bank testing logs of the emergency generator were completed as required.


Findings:

Record review of monthly generator logs for May to July 2019 showed the monthly load bank testing of the facility's emergency generator did not document beginning and ending run times to verify the minimum of the required 30 minute monthly load bank testing. For example, the 06/12/19 facility documentation for the load bank test only shows a run time number of 94.6 hours with no beginning or end time reference. Each monthly review provided did not show a beginning or end time to confirm the minimum of 30 minutes per month.

On 08/06/19 at 2:43 pm the surveyor had asked Staff D for January-April 2019 monthly generator load bank reports but did not bring each of the months. The surveyor asked Staff D why they did not bring each of the months requested in addition to the beginning and end times for the monthly load banks missing Staff D stated the facility keeps all of the documents on the computer. Staff D stated the maintenance staff perform the load bank testing and only use the form that was given to the surveyor.