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The facility failed to ensure the emergency preparedness plan was reviewed and updated at least every 2 years in accordance with 42 CFR 482.15(a). The plan must do the following:
1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
2) Include strategies for addressing emergency events identified by the risk assessment.
3) Address patient population, including, but not limited to, persons at-risk; the type of services the facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.
4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation.
This deficient practice could affect all occupants.

Findings include:

Based on review of the facility's EPP with the Manager of Plant Operations and Maintenance Tech II on 12/17/19 at 10:00 a.m., the EEP had a page titled "Review of the EPP" that was last signed and dated on 03/08/17, nine months past due. Based on an interview during records review, the Manager of Plant Operations stated that the provided review form was the only documentation for review of the EPP and the last date recorded was 03/08/17.

Based on record review and interview, the facility failed to ensure the emergency preparedness plan addressed patient population, including, but not limited to, persons at-risk; the type of services the facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans in accordance with 42 CFR 482.15(a)(3). This deficient practice could affect all occupants.

Findings include:

Based on record review with the Manager of Plant Operations and Maintenance Tech II on 12/17/19 at 10:09 a.m., no documentation could be found ensuring the emergency preparedness plan addressed patient population, including, but not limited to, persons at-risk; the type of services the facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. Based on interview at the time of record review, the Manager of Plant Operations stated the policies regarding the type of services the facility has the ability to provide in an emergency; and continuity of operations could not be found.

Based on record review and interview, the facility failed to review and update the Emergency Preparedness Plan (EEP) policies and procedures every two years in accordance with 42 CFR 482.15(b). This deficient practice could affect all occupants.

Findings include:

Based on review of the facility's EPP with the Manager of Plant Operations and Maintenance Tech II on 12/17/19 at 10:00 a.m., the EEP had a page titled "Review of the EPP" that was last signed and dated on 03/08/17, nine months past due. Based on an interview during records review, the Manager of Plant Operations stated that the provided review form was the only documentation for review of the EPP policies and procedures and the last date recorded was 03/08/17.

Based on record review and interview, the facility failed to ensure emergency preparedness policies and procedures include at a minimum, (1) The provision of subsistence needs for staff and patients, whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical, and pharmaceutical supplies. (ii) Alternate sources of energy to maintain - (A) Temperatures to protect patients health and safety and for the safe and sanitary storage of provisions; (B) Emergency lighting; (C) Fire detection, extinguishing, and alarm systems; and (D) Sewage and waste disposal in accordance with 42 CFR 482.15(b)(1). This deficient practice could affect all occupants.

Findings include:

Based on record review with the Manager of Plant Operations and Maintenance Tech II on 12/17/19 at 10:20 a.m., the subsistence needs documentation for the emergency preparedness program was incomplete. Documentation for sewage and waste disposal was not available for review. Based on interview at the time of record review, the Manager of Plant Operations stated the facility does not have a sewage and waste outage policy.

Based on record review and interview, the facility failed to ensure Emergency Preparedness Plan (EPP) include a means to shelter in place for patients, staff, and volunteers who remain in the hospital in accordance with 42 CFR 482.15(b)(4). This deficient practice could affect all occupants.

Findings include:

Based on record review with the Manager of Plant Operations and Maintenance Tech II on 12/17/19 at 11:01 a.m., the facility's EPP did not address procedures to shelter in place for patients, staff, and volunteers. Based on interview at the time of records review, the Manager of Plant Operations stated there was not an individual policy addressing sheltering in place.

Based on record review and interview, the facility failed to ensure Emergency Preparedness Plan (EPP) include the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State or Federally designated health care professionals to address surge needs during an emergency in accordance with 42 CFR 482.15(b)(6). This deficient practice could affect all occupants.

Findings include:

Based on record review with the Manager of Plant Operations and Maintenance Tech II on 12/17/19 at 10:19 a.m., the facility's EPP did not address the use of volunteers in an emergency. Based on interview at the time of records review, the Manager of Plant Operations stated there is not a policy on the use of volunteers during an emergency.

Based on record review and interview, the facility failed to ensure Emergency Preparedness Plan (EEP) include the role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials in accordance with 42 CFR 482.15(b) (8). This deficient practice could affect all occupants.

Findings include:

Based on record review with the Manager of Plant Operations and Maintenance Tech II on 12/17/19 at 10:39 p.m., a policy and procedure for the role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act was not available for review. Based on interview at the time of record review, the Manager of Plant Operations stated the 1135 policy could not be found.

Based on record review and interview, the facility failed to review and update the Emergency Preparedness Plan (EEP) Communication Plan every two years in accordance with 42 CFR 482.15(c). This deficient practice could affect all occupants.

Findings include:

Based on review of the facility's EPP with the Manager of Plant Operations and Maintenance Tech II on 12/17/19 at 10:00 a.m., the EEP had a page titled "Review of the EPP" that was last signed and dated on 03/08/17, nine months past due. Based on an interview during records review, the Manager of Plant Operations stated that the provided review form was the only documentation for review of the EPP Communication Plan and the last date recorded was 03/08/17.

Based on record review and interview, the facility failed to ensure the Emergency Preparedness Plan (EPP) includes primary and alternate means for communicating with the following: (i) Hospital staff. (ii) Federal, State, tribal, regional, and local emergency management agencies in accordance with 42 CFR 482.15(c) (3). This deficient practice could affect all occupants.

Findings include:

Based on record review with the Manager of Plant Operations and Maintenance Tech II on 12/17/19 at 10:41 a.m., the EPP did not address primary and alternate means for communication. Based on interview at the time of records review, the Manager of Plant Operations stated there is a primary and alternant means of communication but agreed the plan did not address primary and alternate means for communication.

Based on record review and interview, the facility failed to reviewe and update the Emergency Preparedness Plan (EEP) Training and Testing Program every two years in accordance with 42 CFR 482.15(d). This deficient practice could affect all occupants.

Findings include:

Based on review of the facility's EPP with the Manager of Plant Operations and Maintenance Tech II on 12/17/19 at 10:00 a.m., the EEP had a page titled "Review of the EPP" that was last signed and dated on 03/08/17, nine months past due. Based on an interview during records review, the Manager of Plant Operations stated that the provided review form was the only documentation for review of the EPP Training and Testing Program and the last date recorded was 03/08/17.

Based on record review and interview, the facility failed to conduct training for the Emergency Preparedness Program (EPP). The Hospital must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training every two years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures in accordance with 42 CFR 482.15(d) (1). This deficient practice could affect all occupants.

Findings include:

Based on record review with the Manager of Plant Operations and Maintenance Tech II on 12/17/19 at 10:53 a.m., no documentation of initial EPP training, EEP training within the last two years, and no documentation to show staff could demonstrate knowledge of the EPP was available for review. Based on an interview at the time of records review, Manager of Plant Operations stated he did not know if training was conducted for the EPP.

Based on record review and interview, The facility failed to conduct at least two exercises to test the emergency plan within the past year. The Hospital must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
a. When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise.
b. If the Hospital experiences an actual natural or man-made emergency that requires activation of the emergency plan, the Hospital is exempt from engaging its next required full-scale in a community-based or individual, facility-based full-scale functional exercise for 1 year following the onset of the actual event.
(ii) Conduct an additional exercise that may include, but is not limited to the following:
a. A second full-scale exercise that is community-based or an individual, facility-based functional exercise.
b. A mock disaster drill; or
c. A tabletop exercise or workshop that is led by a facilitator that includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the Hospital response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the Hospital emergency plan, as needed in accordance with 42 CFR 482.15(d)(2). This deficient practice could affect all occupants.

Findings include:

Based on record review with the Manager of Plant Operations and Maintenance Tech II on 12/17/19 at 11:02 a.m., there was documentation of a community based exercise completed on 03/19/19, but there was no documentation of an additional exercise within the last year. Based on interview at the time of records review, the Manager of Plant Operations stated there has not been an additional exercise conducted within the past 12 months.

Based on record review and interview, the facility failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72, as required by LSC 101 Sections 19.3.4.5.1 and 9.6. NFPA 72, Section 14.3.1 states that unless otherwise permitted by 14.3.2, visual inspections shall be performed in accordance with the schedules in Table 14.3.1, or more often if required by the authority having jurisdiction. Table 14.3.1 states that the following must be visually inspected semi-annually:
a. Control unit trouble signals
b. Remote annunciators
c. Initiating devices (e.g. duct detectors, manual fire alarm boxes, heat detectors, smoke detectors, etc.)
d. Notification appliances
e. Magnetic hold-open devices
This deficient practice could affect all building occupants.

Findings include:

Based on record review with the Manager of Plant Operations and Maintenance Tech II on 12/17/19 at 11:09 a.m., an annual visual/functional fire alarm inspection conducted on 01/04/19 was provided but documentation regarding a visual semi-annual fire alarm system inspection conducted six months after the anunal fire alarm inspection was not provided. Based on interview at the time of record review, the Maintenance Tech II stated a visual semi-annual inspection of the fire-alarm system was not completed.

Based on record review and interview, the facility failed to provide 1 of 1 correct written policy for the protection of residents indicating procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period in accordance with LSC, Section 9.6.1.6. This deficient practice affects all occupants.

Findings include:

Based on record review with the Manager of Plant Operations and Maintenance Tech II on 12/17/19 at 11:29 a.m., the facility did not provide documentation of a fire watch policy for when the fire alarm system is out of order. Based on interview during the record review, the Manager of Plant Operations stated the facility does not have a written fire watch policy.

Based on record review and interview, the facility failed to maintain 1 of 1 sprinkler system in accordance with LSC 9.7.5. LSC 9.7.5 requires all automatic sprinkler systems shall be inspected and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 edition, Table 5.1.1.2 indicates the required frequency of inspection and testing. NFPA 25, 5.2.4.1 states gauges on wet pipe sprinkler systems shall be inspected monthly and gauges on dry systems (5.2.4.2) shall be inspected weekly to ensure normal water or air pressure is being maintained. NFPA 25 13.3.2.1 states valves should be inspected weekly or valves secured locks or supervised (13.3.2.1.1) shall be permitted to be inspected monthly. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Manager of Plant Operations and Maintenance Tech II on 12/17/19 at 10:29 a.m., no monthly inspection of the wet pipe sprinkler system's gauges and valves were available for review. During an interview at the time of record review, the Maintenance Tech II stated the inspection of gauges and valves were not recorded.

Based on record review and interview, the facility failed to provide 1 of 1 correct written policies in the event the automatic sprinkler system has to be placed out-of-service for 10 hours or more in a 24-hour period in accordance with LSC, Section 9.7.5. LSC 9.7.6 requires sprinkler impairment procedures comply with NFPA 25, 2011 Edition, the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 15.5.2 requires nine procedures that the impairment coordinator shall follow. A.15.5.2 (4) (b) states a fire watch should consist of trained personnel who continuously patrol the affected area. Ready access to fire extinguishers and the ability to promptly notify the fire department are important items to consider. During the patrol of the area, the person should not only be looking for fire, but making sure that the other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. This deficient practice could affect all occupants in the facility.

Findings include:

Based on record review with the Manager of Plant Operations and Maintenance Tech II on 12/17/19 at 11:29 a.m., the facility did not provide documentation of a fire watch policy for when the fire sprinkler system is out of order. Based on interview during the record review, the Manager of Plant Operations stated the facility does not have a written fire watch policy.

Based on observation and interview, the facility failed to ensure 1 of 1 wet locations were provided with ground fault circuit interrupter (GFCI) protection against electric shock. LSC 19.5.1.1 requires utilities comply with Section 9.1. LSC 9.1.2 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code. NFPA 70, NEC 2011 Edition at 210.8 Ground-Fault Circuit-Interrupter Protection for Personnel, states, ground-fault circuit-interruption for personnel shall be provided as required in 210.8(A) through (C). The ground-fault circuit-interrupter shall be installed in a readily accessible location. NFPA 70, 517-20 Wet Locations, requires all receptacles and fixed equipment within the area of the wet location to have GFCI protection. Note: Moisture can reduce the contact resistance of the body, and electrical insulation is more subject to failure. This deficient practice could affect staff that use the medication room.

Findings include:

Based on observation with the Manager of Plant Operations and Maintenance Tech II on 12/17/19 at 12:29 p.m., there was an electric receptacle within three feet of the sink in the Medication Room. The electric receptacle was not provided with GFCI protection at the receptacle or at the breaker box. Based on interview at the time of observation, the Maintenance Tech II checked the receptacle and the breaker to the receptacle and stated there is no GFCI protection.

Based on record review and interview, the facility failed to maintain testing of 1 of 1 elevator firefighter recall in accordance with 9.4.6, Elevator Testing. LSC 9.4.6.2 states that all elevators with fire fighters' emergency operations in accordance with 9.4.3 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME A17.1/CSA B44, Safety Code for Elevators and Escalators. This deficient practice would affect all occupants.

Findings include:

Based on record review with the Manager of Plant Operations and Maintenance Tech II on 12/17/19 at 12:12 p.m., the monthly testing form for the elevator firefighter recall was missing testing for the months of January and August through November of 2019. Based on interview at the time of record review, the Maintenance Director confirmed the elevator was equipped with a firefighter recall and the tests were not conducted on the aforementioned months.

Based on record review and interview, the facility failed to provide 1 of 1 written emergency fire safety plan that incorporated all items listed in NFPA 101, Section 19.7.2.2.
1. Use of alarms.
2. Transmission of alarms to fire department.
3. Emergency phone call to fire department
4. Response to alarms.
5. Isolation of fire.
6. Evacuation of immediate area.
7. Evacuation of smoke compartment.
8. Preparation of floors and building for evacuation.
9. Extinguishment of fire.
This deficient practice could affect all occupants.

Findings include:

Based on record review with the Manager of Plant Operations and Maintenance Tech II on 12/17/19 at 12:29 p.m., the provided facility's fire safety plan titled "Fire Alarm Response" did not address the following items:
a) Extinguishment of fire. The fire safety plan did indicate the type of fire extinguishers in the building but did not address how to extinguish a fire with an extinguisher.
b) Emergency phone call to fire department. The fire safety plan did not indicate calling the fire department upon discovery of a fire.
Based on interview at the time of records review, the Manager of Plant Operations agreed the aforementioned required items were not included in the fire safety plan.

Based on observation, record review and interview, the facility failed to ensure the hospital grade electrical receptacles in 13 of 13 patient sleeping rooms were tested after initial installation, replacement, or servicing of the device. NFPA 99, Health Care Facilities Code 2012 Edition, Section 6.3.4.1.1 where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device. 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data. Section 6.3.3.2 states Receptacle Testing in Patient Care Rooms requires the physical integrity of each receptacle shall be confirmed by visual inspection. The continuity of the grounding circuit in each electrical receptacle shall be verified. Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed; and retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 grams (4 ounces). This deficient practice could affect all patients.

Findings include:

Based on observations during a tour of the facility on Manager of Plant Operations and Maintenance Tech II on 12/17/19 between 12:00 p.m. and 1:00 p.m., the facility's 13 patient sleeping rooms each were provided with 4 hospital grade electrical receptacles. During record review with the Manager of Plant Operations and Maintenance Tech II at 11:14 a.m., there was no documentation available to show electrical receptacles in the patient sleeping rooms were tested after initial installation or if any had been replaced or serviced and then retested.